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Management of an Acute Asthma Attack

in Adults (aged 16 years and older)


National Clinical Guideline No. 14

November 2015
Guideline Development Group
The National Clinical Guideline on Management of an Acute Asthma Attack in Adults was
developed by a sub-group of the National Clinical Programme for Asthma (NCPA). The Guideline
Development Group was chaired by Professor Pat Manning.

Clinical Strategy and Programmes Division

Using this National Clinical Guideline


The aim of this guideline is to assist health care professionals in all healthcare settings, (pre-hospital
emergency care, primary care and secondary care including Emergency Department/ Acute
Medical Unit and specialist services including maternity, mental health, disability and specialised
orthopaedic centres) in assessing and making decisions on the management of acute asthma
in adults and to assist policy makers and those planning acute services for adult asthma patients.

The National Clinical Programmes including the National Clinical Programme for Asthma
(NPCA) were set up through the HSE’s Clinical Strategy and Programmes Division with the aim
of delivering better care and outcomes through the best use of resources, delivered through
standardised care pathways and models of care for the patient journey throughout the national
health system. The Programmes are focused on transforming the way care is delivered in Ireland,
with the overarching aim of improving the quality and safety of patient care. The National
Clinical Programmes have a direct impact on the patient experience and are improving care in
a number of ways through defining the patient journey and this includes the development and
dissemination of clinical evidenced-based guidelines to standardise and improve treatment.
The development and dissemination of this Guideline on the Management of an Acute Asthma
Attack in Adults is in line with this policy. This guideline provides recommendations based on
current evidence for best practice in the management of an asthma attack in adults including
pregnant women.

This National Clinical Guideline is available at:


www.health.gov.ie/patient-safety/ncec and www.hse.ie/asthma

Reference of National Clinical Guideline


National Clinical Guideline No. 14 should be referenced as follows:
Department of Health – Management of an Acute Asthma Attack in Adults
National Clinical Guideline No. 14.
November 2015. ISSN 2009-6259.

Disclaimer
This guideline is not intended to be construed or to serve as a standard of care. Standards of
care are determined on the basis of all clinical data available for an individual case and are
subject to change as scientific knowledge and technology advance and patterns of care
evolve. Adherence to guideline recommendations will not ensure a successful outcome in
every case, nor should they be construed as including all proper methods of care or excluding
other acceptable methods of care aimed at the same results. The ultimate judgement must be
made by the appropriate healthcare professional(s) responsible for clinical decisions regarding
a particular clinical procedure or treatment plan. This judgement should only be arrived at
following discussion of the options with the patient, covering the diagnostic and treatment
choices available. It is advised, however, that significant departures from the national guideline
should be fully documented in the patient’s case notes at the time the relevant decision is taken.
National Clinical Effectiveness Committee (NCEC)

The National Clinical Effectiveness Committee (NCEC) was established as part of the Patient
Safety First Initiative. The NCEC is a partnership between key stakeholders in patient safety.
NCEC’s mission is to provide a framework for national endorsement of clinical guidelines and
audit to optimise patient and service user care. The NCEC has a remit to establish and implement
processes for the prioritisation and quality assurance of clinical guidelines and clinical audit so
as to recommend them to the Minister for Health to become part of a suite of National Clinical
Guidelines and National Clinical Audit.

The aim of the suite of National Clinical Guidelines is to provide guidance and standards for
improving the quality, safety and cost-effectiveness of healthcare in Ireland. The implementation
of these National Clinical Guidelines will support the provision of evidence-based and consistent
care across Irish healthcare services.

NCEC Terms of Reference


1. Provide strategic leadership for the national clinical effectiveness agenda.
2. Contribute to national patient safety and quality improvement agendas.
3. Publish standards for clinical practice guidance.
4. Publish guidance for National Clinical Guidelines and National Clinical Audit.
5. Prioritise and quality assure National Clinical Guidelines and National Clinical Audit.
6. Commission National Clinical Guidelines and National Clinical Audit.
7. Align National Clinical Guidelines and National Clinical Audit with implementation levers.
8. Report periodically on the implementation and impact of National Clinical Guidelines and
the performance of National Clinical Audit.
9. Establish sub-committees for NCEC work streams.
10. Publish an Annual Report.

Information on the NCEC and endorsed National Clinical Guidelines is available at:
www.health.gov.ie/patient-safety/ncec
Acknowledgements

I am grateful to all who contributed to the development of this National Clinical Guideline and
in particular it would not have been possible without the enormous contribution of the members
of the National Clinical Programme for Asthma’s Guideline Development Group (GDG) the
Working Group (WG) and Clinical Advisory Group (CAG) and the reviewers (a full list is available
in Appendix 1). In addition, I would also like to acknowledge the invaluable input and assistance
in the process of completing the guideline of the following; Ms Michelle O’Neill, Senior Health
Economist, Health Technology Assessment Directorate, Health Information and Quality Authority;
Prof Stephen Lane, Chair (Clinical Advisory Committee-NCPA); Dr. Ina Kelly, Specialist in Public
Health Medicine (NCPA); the Chair, Prof Hiliary Humphrys and committee of National Clinical
Effectiveness Committee; Dr Kathleen Mac Lellan, Director of Clinical Effectiveness, and Dr Sarah
Condell and Rosarie Lynch, CMO Office, Department of Health; colleagues in the Health Service
Executive (HSE); Mr. Gethin White, Clinical Librarian, library services; National Directors, Clinical
Strategy and Programmes Division; Dr. Barry White and Dr. Aine Carroll, Prof Tim McDonald,
National Lead COPD; Valerie Twomey, Carmel Cullen, Maeve Raeside and Linda Kearns; the
CEO of Irish Thoracic Society Suzanne McCormack, and past and current presidents of the
Society, Dr Terry O’Connor, Dr. Ed McKone and Prof Anthony O‘Regan; and for support from the
Royal College of Physician in Ireland, it’s past and current President Prof John Crowe and Prof
Frank Murray and the CEO Leo Kearns; the CEO Mr Kieran Ryan and members of the Quailty
in Practice Committee of the Irish College of General Practitioners are also acknowledged. I
would like to thank all of these collegaues for sharing their time and expertise.

I would also like to express our thanks to the following; Dr Veronica Lambert and her team
at Dublin City University for their work on the guideline appraisal; Dr Roberta James, SIGN
Programme Lead and her colleague Karen King and the Scottish Intercollegiate Guidelines
Network (SIGN), Edinburgh, Scotland for use of the sections of the BTS SIGN Asthma Guidelines
included in this document; and in addition, I would also like to thank Suzanne Hurd and Board of
GINA (Global Initiative on Asthma) for access to use of sections of GINA guidelines on asthma.

_______________________________________

Prof Pat Manning


Chairperson - Guideline Development Group
Clinical Lead, National Clinical Programme for Asthma
Table of Contents

Section 1: Background 7
1.1 Need for a National Clinical Guideline 7
1.2 Clinical and financial impact of acute asthma 7
1.2.1 Budget impact of the proposed guidelines 7
1.2.2 The implications for service development in guideline implementation 8
1.3 Overview of epidemiology of asthma 9
1.3.1 Current levels of asthma in Ireland 9
1.3.2 Asthma deaths 9
1.4 Aim of National Clinical Guideline 10
1.5 Scope of National Clinical Guideline, target population and target audience 10
1.6 Governance 11
1.6.1 Conflict of interest statement 11
1.6.2 Sources of funding 12
1.7 methodology and literature review 12
1.7.1 Background 12
1.7.2 Objectives 12
1.7.3 Method 13
1.7.4 Strand 1: Systematically searching, retrieving and screening
clinical guidelines 13
1.7.5 Strand 2: Assessment of guideline quality 18
1.7.6 Strand 3: Analysis of guideline recommendations 20
1.7.7 Concluding summary 22
1.8 Grading of recommendations 23
1.9 External review 24
1.10 Procedure for update of National Clinical Guideline 24
1.11 Implementation of National Clinical Guideline 24
1.11.1 Facilitation of implementation 25
1.11.2 Potential barriers to implementation 25
1.12 Tools to assist the implementation of the National Clinical Guideline 25
1.13 Roles and responsibilities 25
1.13.1 Local hospital services 25
1.13.2 Primary care services 26
1.14 Audit criteria 27
1.15 Unlicensed medicines 27

Section 2: National Clinical Guideline recommendations 28


2.1 Summary of National Recommendations. 28
2.2 National Recommendations 30
2.2.1 Risk factors for developing fatal asthma 30
2.2.2 Management of acute asthma attacks 32
2.2.3 Management of acute asthma in pregnancy 44
2.2.4 Discharge and follow-up 45

Section 3: Appendices and references 49


Appendix 1
Guideline Development Group 49
Appendix 1.1 Terms of reference 49
Appendix 1.2 Membership of Guideline Development Group 49
Appendix 1.3 Consultation process 52
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Appendix 2
Summary of tools to assist in implementation of National Clinical Guideline 53
Appendix 2.1 Emergency treatment protocols for management of acute adult
asthma 54
Appendix 2.2 Emergency treatment care bundles for management of acute
adult asthma 56
Appendix 2.3 Discharge letter, fax, email template for management of acute
adult asthma 59
Appendix 2.4 Audit form for emergency asthma care 60
Appendix 2.5 Asthma management plan 61
Appendix 2.6 Peak flow measurements 63
Appendix 2.7 Medications in acute asthma 64

Appendix 3
Search sources and outputs 65
Appendix 3.1 Guideline clearing houses and organisations which develop
guidelines and/or support evidence based practice; search
sources and outputs 65
Appendix 3.2. International asthma, thoracic and lung associations. 68
Appendix 3.3 Grey literature databases 75
Appendix 3.4 Electronic databases 76
Appendix 3.5 Internet search engines 78

Appendix 4
Characteristics of retrieved guidelines 80

Appendix 5
Sample – AGREE II Instrument 84

Appendix 6
Protocol for guideline appraisal training phase 85

Appendix 7
MY AGREE PLUS 91

Appendix 8
Quality appraisal visual graphs 92

Appendix 9
Revisions to quality appraisal visual graphs 100

Appendix 10
Group consensus appraisal scores 109

Appendix 11
Description of grades of recommendations for each guideline 113

Appendix 12
Data extraction recommendation matrix 115

Appendix13
Tool 13: Evaluation sheet – search and selection of evidence 132
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Appendix 14
Tool 14: Evaluation sheet – scientific validity of guidelines
(Consistency between evidence, its interpretation and recommendations) 134

Appendix 15
Tool 15: Evaluation sheet – acceptability/applicability 136

Appendix 16
Glossary of abbreviations 137

Appendix 17
Budget impact assessment 139
Appendix 17.1 Economic impact report 139
Appendix 17.2 Budget-cost implications for implementation of acute adult
guidelines 147
Appendix 17.3 Economic search methodology 155

Appendix 18
References 158
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List of tables
Table 1 Clinical Questions 11
Table 2 Inclusion and Exclusion Criteria 14
Table 3 Quality Score for each six AGREE II domains for both BTS/SIGN and GINA 20
Table 4 Roles and responsibilities of stakeholders in relation to the National
Clinical Guideline 26
Table 5 Levels of Severity for Adults 36
Table 6 Cost of attendance for training HSE associated staff 151
Table 7 Cost of attendance at training for other staff 152
Table 8 Estimated costs and possible savings with Implementation of Acute
Asthma Attack in Adults Guideline 156
Table 9 Search Methodology 158

List of figures
Figure 1 Asthma Epidemiology – based on 2011 data 9
Figure 2 Flowchart of search outputs and screening 17
Figure 3 Group consensus appraisal scores for the BTS/SIGN Guideline 19
Figure 4 Group consensus appraisal scores for the GINA Guideline 19
Figure 5 Rating of overall quality of the guideline 20
Figure 6 Flow Diagram of Retrieved Studies 159
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1 Background

1.1 Need for a National Clinical Guideline


There are no grounds for complacency regarding asthma in the Republic of Ireland, as we
have one of the highest rates of asthma prevalence in the world (1, 2). It is a chronic medical
condition, which for many patients, begins in childhood, and is thus life-long. A great number
of patients live and work without being free of regular asthma symptoms, due primarily to
having uncontrolled disease (3), even despite the availability of well-constructed international
evidenced-based guidelines and excellent, accessible and safe medicines. Uncontrolled
asthma leads to poor quality of life for many of these patients as well as their families and
caregivers. It is a condition often associated with increased cost due to out of hours GP visits,
emergency department visits, and hospitalisation for acute asthma attacks as well as the
associated loss of time from work and school (4).

The National Clinical Programme for Asthma (NCPA) was set up to design and standardise the
delivery of high quality asthma care to all who need it. The NCPA also focuses on improving
asthma control in the community, reducing acute asthma attendances at emergency
departments, in-patient admissions and needless deaths from asthma. A specific priority solution
to help manage patients with acute asthma attacks has been the development of this national
evidence based guideline by the NCPA.

1.2 Clinical and financial impact of acute asthma

1.2.1 Budget impact of the proposed guideline


This guideline provides clear guidance for the assessment and treatment of acute asthma in
general practice, by paramedic services, the Emergency Department (ED) and in the acute
hospital for adults. The estimated annual cost of care for acute asthma attacks in the Republic
of Ireland is of the order of €6.5 million and much of this cost relates to adult admissions (see
Appendix 17). Hospitalisation accounts for between 20 and 25% of the overall cost (5).
International research has identified that the majority of hospital admissions for asthma are
emergency admissions of which 70% may have been preventable with appropriate early
intervention (6, 7). An acute attack requiring hospital attention at the Emergency Department
(ED) or in-patient care represents a serious failure of asthma control. In that situation, patients
will need to have access to local, easily accessible and competent services in an emergency,
which may be their GP practice, GP out-of-hours/urgent care services (GPOOH), ED or in-
hospital care. About 15% of patients relapse following an asthma attack (8), especially if seen in
an ED.

Patients with an acute attack of asthma are at increased risk of death and readmission for
asthma if not managed appropriately (8). Patients who attend GPOOH, ED and those who are
admitted to hospital for acute asthma should be followed up by attending their GP within 2
working days of discharge for ongoing asthma management. International best practice (8)
recommends that all patients admitted to hospital should be followed up on discharge from
hospital in a medical specialist clinic for 1 year (in conjunction with their GP) until stable.

The cost impact analysis focuses on two costing areas. This is detailed in Appendix 17.

Staff training:
The main costs for guideline implementation are the costs associated with structured training
for clinical staff in hospital and GPOOH settings on acute asthma guideline managed care. It is
critical that medical staff involved with acute asthma patients have the knowledge and training
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to manage these patients appropriately. It is estimated that the overall cost of training relevant
HSE staff would be €193,104, but these costs are mostly opportunity costs.

Possible additional cost implications arising from implementing the guidelines:


Additional costs that have been reviewed but are essentially either cost neutral or are associated
with the implementation of an overall Asthma Model of Care Chronic Disease Management
Programme for primary care linked to specialist care include the following:
• Recommendation that a spacer device is used with a pressurised multidose inhaler (pMDI)
inhaler in mild-moderate asthma attacks rather than wet nebulisation for salbutamol
bronchodilation where possible
• Recommendations on medications e.g. inhaled steroids and oral steroids in acute asthma
attacks
• Recommendation of follow up with a GP within 2 working days of discharge from ED
• Recommendations on follow up in the medical specialist/nurse led OPD clinic for 1 year for
patients admitted to hospital with acute asthma following discharge
• Recommendation that all patients have a peak flow meter reading on assessment by
paramedic and on admission to GPOOH, ED and Hospital.

In relation to the above, it is estimated that there are possible annual savings of €179,978 from
reducing the use of nebulisers in the ED. Additionally, better management by specialist/asthma
nurse led clinics following discharge, leading to non-attendances at ED and GPOOH and
reduced admissions by 20%, could result in estimated annual savings of €1,380,000.

1.2.2 The implications for service development in guideline implementation


The implementation of the guideline will have implications for service development, such as:
• All HSE staff involved with patients experiencing an asthma attack should have appropriate
training in arranging rapid assessment for asthma, in all healthcare settings in which patients
may attend in an emergency.
• Pre-hospital emergency care practitioners may be the first health care professionals that
people will encounter in an emergency. They need to have the right skills and training to
provide support before they can reach more specialist treatment. They also need to be
able to distinguish between people who need hospitalisation and those who could safely
be redirected to community services.
• GP Out–of-hours (GPOOH) centres are increasingly the first port of call for people experiencing
an asthma attack. Therefore medical/nursing staff in these settings need to be as well-
trained as in all other settings and in particular need to have close communication with
primary care to ensure prompt and appropriate follow-up after the episode. It is particularly
important that out-of-hours services are aware of the people at greatest risk of having an
attack and are knowledgeable and competent in dealing with asthma attacks.
• Hospital staff, including Emergency Department and in-patient hospital personnel involved
in triage, assessment and management of acute asthma should have the appropriate
knowledge and training in acute asthma assessment and ongoing care for this condition.
• There is over-use of nebulisers in acute situations. Delivery of short acting bronchodilators
by nebuliser instead of by standard inhaler with a spacer can encourage a reliance on
hospital care, and lead to repeat hospital attendances by patients, when delivery using an
inhaler and spacer may be adequate. This guideline recommends that Hospital Emergency
Departments, GPOOH and urgent care centres do not use nebulisers routinely for treatment
of acute attacks, except where appropriate.
• Patients who are admitted to hospital should be managed in a ward where staff including
nurses, have adequate training and experience in monitoring acutely ill, asthma patients
and are proficient at administering appropriate medications for this.
• Every acute hospital admissions unit should have a senior clinical individual who is responsible
for ensuring that asthma care across all departments conforms to the Management of an
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Acute Asthma Attack in Adults guideline, and to ensure that records and audit processes
and outcomes are identified and stored.
• Implementation of bundles of care for acute asthma care to encourage adherence to best
practice guidelines is recommended locally.

1.3 Overview of epidemiology of asthma

53
deaths

99 discharges
from ICU

5,396 inpatients
discharges

19,370 attendees in ED

Approximately 50,000 asthma attendances


to GPOOH services

248,400 patients with non-controlled asthma

460,000 people in the Republic of Ireland with doctor-diagnosed-asthma

Figure 1 Asthma Epidemiology – based on 2011 data

1.3.1 Current levels of asthma in Ireland


Asthma is a high prevalence disease in the Republic of Ireland with nearly 460,000 people
estimated to have been diagnosed with asthma and nearly a quarter of a million may have
asthma that is not controlled (2). About 50,000 patients are estimated to use the GP out-of-
hours service for the treatment of acute asthma in a year. Over 19,000 people visit Emergency
Departments annually with acute asthma and over 5,000 patients are admitted to hospital (9).
Of these about 100 are so severely ill that they are admitted to an intensive care unit.

1.3.2 Asthma deaths


About one person dies from Asthma every week in Ireland (9).

Confidential enquiries into asthma deaths or near fatal asthma attacks from the UK and Ireland
have identified a number of factors which contribute to an asthma death. Most deaths from
asthma occur before admission to hospital, and usually occur in patients who have chronic
asthma, who are on inadequate inhaled corticosteroid therapy with increased reliance on
inhaled ß2-agonists (10). There is generally poor perception by the patient or physician caring for
the patient of the overall severity of the asthma attack. In addition, inadequate management
in the acute event including using sedation in some cases are also factors linked to asthma
deaths. Deaths from asthma, while uncommon, are generally preventable and occur usually
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in association with an acute attack. Although most of these patients have chronically severe
asthma, in a minority the fatal attack has occurred suddenly in a patient with mild or moderately
severe background disease. Most asthma deaths occur before admission to hospital.
Many deaths occur due to patients receiving inadequate treatment with inhaled steroids or
steroid tablets and/or inadequate objective monitoring of their asthma, where follow up was
inadequate in some and others should have been referred earlier for specialist advice (10).

1.4 Aim of National Clinical Guideline


The aim of the National Clinical Guideline is to assist health care professionals in all healthcare
settings, (pre-hospital emergency care, primary care and secondary care including ED/AMU
and specialist services including maternity, mental health, disability and specialised orthopaedic
centres) in assessing and making decisions on the management of acute asthma in adults by
outlining evidence based threatment protocols. It also aims to assist policy makers and those
planning acute services for adult asthma patients.

The expected benefits resulting from the implementation of this guideline include:
• A reduction in asthma related deaths in adults
• Improved patient experience, safety and quality of care
• Raised levels of awareness among healthcare professionals on how to manage acute
asthma attacks in adults, including pregnant women
• Improved efficiency in the admission, care, discharge and follow-up of adults experiencing
an acute asthma attack

1.5 Scope of National Clinical Guideline, target population and target audience
These guidelines are for the management of acute adult asthma attack in all care settings
including primary and secondary care and specialist centres. The guideline considers all adult
patients (>16 years) with a diagnosis of asthma.

This guideline does not cover patients whose primary respiratory diagnosis is not asthma, for
example those with chronic obstructive pulmonary disease (COPD) or cystic fibrosis (CF),
although these patients may also have asthma and the principals outlined in these guidelines
may also apply to the management of their asthma component symptoms.

The scope of the recommendations set out in this document does not extend to children or
youth populations, or difficult/severe but stable asthma. Nor do the recommendations relate
to specific settings, such as primary care, and/or populations, such as pregnant women, unless
the recommendations refer to the management of an acute asthma attack in such settings/
populations.

There are separate Acute Paediatric Asthma Guidelines which have been developed by the
National Clinical Programme for Asthma.
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The recommendations set out in this National Clinical Guideline seek to address the following
clinical questions:

Table 1 Clinical questions


What is best practice management of patients with an acute asthma attack in primary care?
What are the criteria for referral to the Emergency Department for a patient with an acute asthma
attack?
What are the hospital admission criteria with an acute asthma attack?
What are the signs to distinguish the severity of an asthma attack?
What are the key components of an objective assessment of an attack in the adult asthma patient?
What is the best practice treatment of the adult asthma patient during an acute attack?
What is best practice management of an acute asthma attack in pregnancy?
What discharge and follow-up planning is required for patients with an acute asthma attack?
What role can patient education play in asthma management following an acute attack?
What should the follow up process be after an attack?

1.6 Governance
Governance of the guideline development process was provided by a multidisciplinary
Guideline Development Group (GDG) which was chaired by the Clinical Lead for the National
Clinical Programme for Asthma.

The GDG was responsible for the development and delivery of this National Clinical Guideline
and included representatives from relevant medical groups with expertise in the diagnosis,
treatment and care of patients with asthma.

Consultation, review and input to the guideline was sought from the Royal College of Physicians
of Ireland Clinical Advisory Group (for the NCPA) nominated by the Irish Thoracic Society, other
National Clinical Programmes and patient organisations.

The Clinical Advisory Group for the NCPA also had an oversight role.

The evidence base for this guideline is built on existing international guidelines which have been
adapted to reflect care in an Irish healthcare setting. The main evidence utilised in this guideline
is that from the Scottish Intercollegiate Guideline Network/British Thoracic Society – British
Guideline on the management of asthma, 2014 and the Global Initiative for Asthma (GINA),
updated 2015.

Permissions were sought and kindly granted from the Scottish Intercollegiate Guidelines Network
(SIGN) and Global Initiative for Asthma (GINA) for use of their guidelines in the development of
these guidelines.

1.6.1 Conflict of interest statement


Professor Pat Manning, National Clinical Programme Lead and Chair of the GDG, is a member
of the GINA International Assembly as the Irish representative. Prof Manning’s role is advisory and
non-remunerated or supported and does not involve reviewing or making recommendations on
the guidelines content; this is the role of Scientific Committee and Board. The GINA Assembly,
are international asthma experts from many countries who meet twice a year with members of
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the GINA Board (at the American Thoracic Society and European Respiratory Society Annual
Conferences) to share information about upcoming changes to recommendations on asthma
management, also issues of education, prevention and strategies for local dissemination of the
GINA management programme. Prof. Manning has also been involved in the implementation
of the GINA asthma management guideline in conjunction with the Irish College of General
Practitioners and the Asthma Society of Ireland, which is regularly updated.

No conflicts of interest were declared by the GDG members.

1.6.2 Sources of funding


No external funding was requested or received in developing these guidelines however the
NCEC funded the undertaking of the literature review and budget impact assessment.

1.7 Methodology and literature review


A systematic evidence review of literature was undertaken in formulating this guideline. A
research team from the Dublin City University (DCU) School of Nursing and Human Sciences, led
by Dr Veronica Lambert, was commissioned by the National Clinical Effectiveness Committee
(Department of Health) to carry out the review.

1.7.1 Background
The goal of the review was to support the decision to develop a National Clinical Guideline
(NCG) for the Management of an Acute Asthma Attack in Adults. This NCG was to support the
Model of Care for the HSE National Clinical Programme for Asthma in Ireland, and be quality
assured by the National Clinical Effectiveness Committee (NCEC). The aim of Dr Lambert and
her team was to deliver a systematic review of clinical guidelines used in primary and secondary
care contexts. This includes general practice, paramedic services, emergency departments
and acute adult hospital contexts, for the assessment and management of the acute adult
asthma patient to improve clinical outcomes (including reduction of morbidity and mortality)
and quality of life for adults living with asthma in Ireland.

1.7.2 Objectives
The purpose of the review was to complete a systematic search for and review of guidelines
to support the adaptation of recommendations for the Irish National Clinical Guideline for the
Management of an Acute Asthma Attack in Adults.

The following three objectives were addressed;


1. Identification of developed evidence based clinical guidelines related to the management
of acute asthma for adult patients through the conduct of a systematic search over a
specified period (2011-2015) in line with the ADAPTE process (11)
2. Co-ordination of a quality assessment of the retrieved clinical guidelines using the AGREE II
tool (12)
3. Analysis of the recommendations of the retrieved clinical guidelines and their applicability
to the decisions for inclusion of the recommendations in the Irish National Clinical Guideline
for the management of acute asthma attacks in adult patients

These objectives were confirmed with the HSE Asthma Guideline Development Group (GDG)
and DoH Clinical Effectiveness Unit (CEU) through the nominated contact points prior to the
commencement of the review.
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1.7.3 Method
The methodology for this review followed the ADAPTE process as outlined in the Guideline
Adaptation Resource Toolkit (The ADAPTE Collaboration 2009) (11) and the National Clinical
Effectiveness Committee (NCEC) Guideline Development Manual of 2013 (13) with regard to
considering clinical guideline evidence for the review; search methods; guideline selection
and assessment and decisions around adaptation of guideline recommendations. Assessment
of guideline quality was guided by the AGREE II (Appraisal of Guidelines for Research and
Evaluation) Instrument (Brouwers et al. 2010) (12).

The work plan for this systematic guideline review was structured around 3 work strands;

Strand 1 involved systematically searching over a specified period (2011-2015)


various literature sources in line with the ADAPTE process to identify guidelines
related to the management of acute asthma in adults.

Strand 2 involved coordinating the quality assessment among 4 appraisers (3


from DCU and 1 from the GDG) of the retrieved guidelines using the AGREE II
tool.

Strand 3 involved an analysis of the retrieved guidelines recommendations to


evaluate their applicability to the decisions for inclusion in the Irish National
Clinical Guideline.

1.7.4 Strand 1: Systematically searching, retrieving and screening clinical guidelines


In line with steps 8, 9 and 10 of the ADAPTE process this strand involved 3 main steps; developing
criteria for considering evidence for inclusion in the review; searching for guidelines and other
relevant documents; and screening retrieved guidelines to determine eligibility for inclusion in
the review.

Criteria for considering evidence for inclusion in the review


The PICOS parameters guiding the review search strategy were;

§ Population: Adult patients >16 years with acute attack of asthma


§ Intervention: Effectiveness of interventions designed to manage acute attacks of asthma in
adult patients >16 years
§ Comparison: Primary and secondary care (including general practice, paramedic services,
emergency departments and acute adult hospital contexts)
§ Outcome: Most clinically effective interventions for managing acute attacks of asthma in
adult patients >16 years
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For the S (i.e. study design) of the PICOS clinical practice guideline (CPG) was specified.

The following inclusion and exclusion criteria were used to assist in the search and retrieval of
guidelines (Table 2).

Table 2 Inclusion and exclusion criteria


Inclusion criteria Exclusion criteria
Evidence-based guidelines only (guidelines must Guidelines written by a single author not on
include a report on systematic literature and explicit behalf of an organisation (for validity a guideline
links between individual recommendations and their needs multidisciplinary input)
supporting evidence)
National and/or international guidelines only Guidelines published without references (it
is necessary to know that the guidelines and
Peer reviewed publications only
recommendations were based on best, current
Written in the English language evidence)

To minimise bias in the review process, the PICOs and inclusion/exclusion criteria were finalised a
priori and agreed with the Steering Committee prior to the commencement of the review.

Search methods for identifying clinical practice guidelines for the review
Drawing on step 8 and the search sources mapped in tool 2 of the ADAPTE process a variety of
sources to retrieve clinical practice guidelines for the management of acute asthma in adults
were searched, including; guideline clearinghouses; websites of organisations which specifically
develop guidelines and/or support evidence based practice; any relevant specialty societies
(i.e. asthmatic, thoracic and lung associations); electronic databases; review databases;
internet search engines; grey literature databases and citation searching retrospectively. These
are outlined below.

Search strategy
The search strategy comprised of three stages. Stage 1 used a limited set of key words to
search a small number of guideline clearinghouses and organisational websites to identify
potentially relevant clinical guidelines (e.g. “asthma management guidelines”; “acute asthma
treatment recommendations”) related to adult asthma management. Similarly a limited
set of free text key words were used to search the database MEDLINE to identify potentially
relevant clinical guidelines related to adult asthma management. A brief review of the retrieved
guidelines was conducted in an effort to expand key words and phrases for a more in-depth
search. Prior to progressing the second search strategy stage, finalised search terms with the
nominated contact points for the HSE Asthma Guideline Development Group (GDG) and DoH
CEU were agreed. Stage 2 repeated stage 1 searches and expanded these searches to other
guideline resources (i.e. guideline clearinghouses and grey literature) and other databases (i.e.
PUBMED, CINAHL, Cochrane) using the full list of key words (both free text and the databases
controlled vocabulary e.g. MeSH, Subject Headings etc.) developed in Stage 1. Stage 3 of the
search entailed searching the reference lists of retrieved eligible guidelines. All searches were
conducted and outputs cross-checked by at least 2 or more members of the review team.

Search sources
The following electronic guideline clearinghouses were searched using various key words
specific to adult acute asthma management and clinical practice guidelines; United States
National Guideline Clearinghouse and Guidelines International Network. See Appendix 3.

The following organisations which develop guidelines and/or support evidence based practice
were also searched; the Scottish Intercollegiate Guidelines Network; the National Institute for
Health and Clinical Excellence; the New Zealand Guideline Group; the Centre for Clinical
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Effectiveness Australia; the National Health and Medical Research Council (Australia); the
Clinical Practice Guideline Portal and the TRIP database. See Appendix 3.

A cross-section of international asthma, thoracic and lung associations were searched,


including; Asthma UK; British Society for Allergy and Clinical Immunology; British Lung Foundation;
Asthma Society of Ireland; American Academy of Allergy Asthma and Immunology; Asthma
and Allergy Foundation of America; National Heart, Lung and Blood Institute; National Institute
of Allergy and Infectious Diseases; Association of Asthma Educators; Centres for Disease Control
and Prevention; National Asthma Education and Prevention Program; Canadian Society of
Respiratory Therapists; Asthma Society of Canada; Allergy and Asthma Information Association;
European Federation of Asthma and Allergy Associations; European Academy of Allergy and
Clinical Immunology; European Lung Foundation; European Respiratory Society; Asthma New
Zealand; The Asthma Foundation; Asthma Australia; National Asthma Council Australia; Australia
Medical Association; GINA - Global Information Network on Asthma; World Allergy Organization;
World Health Organisation; International Primary Care Respiratory Group; Global Allergy and
Asthma Patient Platform; Allergic Rhinitis and it Impact on Asthma; Global Alliance against
Chronic Respiratory Disease; British Thoracic Society; American Thoracic Society; Canadian
Thoracic Society/ Respiratory Guidelines; Irish Thoracic Society; Scottish Thoracic Society; the
Thoracic Society of Australia and New Zealand; the Lung Association Ontario; American Lung
Association and the Lung Association. See Appendix 3.

Other specific grey literature sites searched were the Agency for Healthcare Research and
Quality and Open Grey. See Appendix 3.

The electronic databases of PubMed, MEDLINE, CINAHL and review databases of Cochrane
(inclusive of Cochrane Database of Systematic Review; Database of Abstracts of Review Effects)
and NHS Centre for Reviews and Dissemination were searched using various combinations of
controlled vocabulary and free text words. See Appendix 3.

Finally, internet engines including Google, Bing and Yahoo/AltaVista were searched using key
search terms focused on acute asthma management in adults. If available, these searches
were all narrowed to the English language and limited to the file type pdf. As large volumes
of data return through search engine searches, screening was managed by screening the
first 10 pages (i.e. 100 pdf files on each internet search engine). These internet searches were
completed after all other searches and essentially any guidelines that had not already retrieved
from other sources were looked for. See Appendix 3.

Screening retrieved guidelines


Retrieved guidelines that met the review objectives and inclusion criteria were screened and
selected for further appraisal. This involved 2 or more reviewers independently assessing the
full-text guideline documents against the review objectives and inclusion criteria before a
final decision regarding inclusion/exclusion was confirmed. Any discrepancies were resolved
by discussion with a further review author. Clinical guidelines excluded from the review were
recorded; noting reasons for exclusion. A full audit trail of all the screening processes was
maintained and an adapted PRISMA flow chart was used to visually report the screening and
selection process (Figure 2). For retrieved guidelines, 2 reviewers independently extracted details
on the developing organisation/authors; date of publication, country/language of publication;
dates of the search used by the source guideline developers using the table for recording the
characteristics of the retrieved guidelines as recommended in ADAPTE (see Appendix 4).

Search outputs
The final outputs of the search strategies and screening for eligibility for inclusion in the review
are outlined in Figure 2 below. A total of 2,967 potentially eligible documents were retrieved
for screening across all data sources. After stage 1 screening, 2,915 documents were excluded
because they were not specific to asthma; not systematic evidence based guidelines; not
| Management of an Acute Asthma Attack in Adults | A National Clinical Guideline
16 (aged 16 years and older)

national/international guidelines; not adult populations; published before 2011 and/or were
duplicates. Thus, 53 documents were identified as potentially eligible for inclusion. Following
second screening a further 49 documents were excluded because they were either duplicates,
not a clinical practice guideline; not a national/international guideline; they were based on
other guidelines such as BTS/SIGN (8) or GINA (14) and/or they had no/limited reporting on
methodology in terms of how guidelines were developed and/or grading of evidence. A total
of 4 clinical practice guidelines were retrieved and deemed potentially eligible for inclusion in
the review; including SIGN 141 British guideline on the management of asthma (British Thoracic
Society and Scottish Intercollegiate Guidelines Network – BTS/SIGN updated 2015)(8); the Global
Strategy for Asthma Management and Prevention (Global Initiative for Asthma - GINA updated
2015) (14); the Consensus Statement for the diagnosis and management of asthma from the
Canadian Thoracic Society (updated 2012) (15) and the Australian Asthma Handbook from the
National Asthma Council Australia (updated 2015) (16).

Following discussion with the Asthma Guideline Development Group and further screening of
these 4 potentially eligible clinical documents a decision was made to exclude the Consensus
Statement for the diagnosis and management of asthma from the Canadian Thoracic Society
(updated 2012)(15) and the Australian Asthma Handbook from the National Asthma Council
Australia (updated 2015)(16). Reasons for exclusion were the lack of specific focus on the
management of acute asthma and missing data to enable us to assess the guideline according
to the review criteria. Therefore 2 clinical practice guidelines were left for inclusion in the
review – the SIGN 141 British guideline on the management of asthma (British Thoracic Society
and Scottish Intercollegiate Guidelines Network – BTS/SIGN updated 2015) (8) and the Global
Strategy for Asthma Management and Prevention (Global Initiative for Asthma - GINA updated
2015) (14). The decision to include both of these guidelines in the review was strengthened by
their currency; both guidelines had been updated in 2015. Secondary citation searching of both
these guidelines was completed and no further clinical practice guidelines were identified for
inclusion in the review.
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(aged 16 years and older) 17

Search Sources (n=2967) 2915 guidelines excluded


Guideline clearinghouses and organisations • Guideline clearinghouses and organisations
which develop guidelines and/or support EBP which develop guidelines and/or support
(n=441) EBP (n=426)
Any relevant specialty sources (n=1924) • Any relevant specialty sources (n=426)
Electronic databases (n=3) • Electronic databases (n=3)
Review databases (n=23) • Review databases (n=23)
Internet search engines (n=300) • Internet search engines (n=294)
• Grey literature databases (n=276)
Grey literature databases (n=276)
Reasons for exclusion
• Not specific to asthma; other respiratory
conditions such as COPD/RTI/Rhinitis/chronic
asthma
• Not systematic evidence based guidelines
Stage 1 screening: Titles/Abstracts Reviewed
• Not national/international guidelines
• Not adult population
• Published before 2011
• Duplicates

53 potential guideline documents

Stage 2 screening: Full Texts Reviewed


49 guidelines excluded

Reasons for exclusion


• Duplicates
• Not a clinical practice guideline
• Not national/international
4 guidelines included: met inclusion criteria • Based on other guidelines such as BTS/SIGN
or GINA
BTS/Sign (8) • No/limited reporting on methodology in
terms of how guidelines were developed
GINA (14)
and/or grading of evidence
Canadian Thoracic Society (15)
Australian Asthma Handbook (16)

2 guidelines excluded following discussions


with GDG

Reasons for exclusion


2 guidelines included • Not specifically focused on acute asthma
management
BTS/Sign (8) • Missing data to enable evaluation of clinical
GINA (14) guideline

Figure 2 Flowchart of search outputs and screening


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18 (aged 16 years and older)

1.7.5 Strand 2: Assessment of guideline quality


In line with step 11 of the ADAPTE process, the quality of all guidelines deemed eligible
for inclusion in the review were critically appraised by 4 appraisers using the domains of the
Appraisal of Guidelines Research and Evaluation (AGREE II) Instrument (11) as follows; scope and
purpose; stakeholder involvement; rigour of development; clarity of presentation; applicability;
editorial independence and overall guideline assessment (Appendix 5). There were 2 phases
to the assessment of guideline quality process; (i) a guideline appraisal training phase and (ii) a
main appraisal phase. In phase (i), a protocol for the guideline appraisal process was drafted
(Appendix 6) and a group appraisal was set up via the MY AGREE PLUS (Appendix 7); which
assisted with the individual completion and coordination of the group appraisal results online. All
4 appraisers individually scored the ‘training guideline’ (i.e. BTS/SIGN (8)).

For phase (ii) each appraisal member was given access to the second guideline eligible for
inclusion in the review (i.e. GINA) and a second online group appraisal was set up via the
MY AGREE PLUS online tool. All 4 appraisers individually scored the GINA guideline (14). Once
completed the scores of all the completed AGREE II Instruments were calculated on MY AGREE
PLUS, entered into a spreadsheet and transferred into a graphical format to enable ease of
comparison of guidelines appraisals across the various quality assessment domains in terms
of overall scores and inter-rater agreement (Appendix 9). Following both phases (i and ii), the
appraisal review team met, in conjunction with the DoH CEU, to discuss the results and any
discrepancies in ratings (especially for ratings > score of 1 difference) were resolved through
discussion. Across both the BTS/SIGN (8) and GINA (14) guidelines, the main domains where some
differences in ratings existed were domain 2 stakeholder involvement (item 4, 5); domain 3 rigour
of development (items 8, 10, 11, 13), domain 5 applicability (items 18, 19, 20, 21) and domain
6 (items 22, 23). Most discrepancies were the result of different interpretations of the rating
criteria and considerations and/or data not been sourced, which were easily resolved through
discussion among the 4 appraisers with the CEU acting as arbitrator if required. Following these
discussions, the group appraisals were revised (Appendix 9) and an overall group consensus
appraisal score was calculated as presented in Appendix 10.

Figure 3 below illustrates the overall group consensus ratings for all items across all domains for
the BTS/SIGN (8) guideline. It was agreed that 19 of the 23 items achieved a maximum rating of 7;
the exceptions were items 5, 18, 19, and 20. Item 5 falls under domain 2 stakeholder involvement
and relates specifically to the views and preferences of the target population. While there was
evidence of this within the BTS/SIGN guideline (8) the explicit process and methods used to
gather patient/public views was not outlined, and/or what and how the information gathered
was used to inform the guideline development process and the recommendations; therefore
a rating of 6 was agreed to take account of this missing information. Items 18, 19 and 20 all
belong to domain 5 which relates specifically to applicability - how the guidelines might be
implemented in practice including facilitators and barriers; tools to facilitate application; and
resource and cost implications. There was limited information on all these items in the BTS/SIGN
guideline (8) and/or supporting documents and thus ratings ranging from 4-5 were agreed for
these items. Figure 4 below illustrates the overall group consensus ratings for all items across all
domains for the GINA (14) guideline. It was agreed that 10 of the 23 items achieved a maximum
rating of 7; the exceptions were items 2, 3, 4, 5, 6, 8, 9, 10, 13, 17, 18, 20 and 21. Of these items 3,
4, 6, 8, 9, 10, 17 achieved a score of 6; meaning that the appraisal group felt that some specific
criteria and/or considerations were not explicitly described within the GINA guideline (14) and/
or supporting documents. Of the remaining items, similar to the BTS/SIGN guideline (8), the
appraisal groups sought more specific information on how the views and preferences of the
target population were sought and translated into the recommendations (item 5 with a rating
of 4) and more details on the guideline implementation process, cost and auditing (items 18, 20
and 21 all related to the domain of applicability achieving ratings of 5, 4 and 4 respectively). The
remaining items related to presenting explicit health questions (item 2 rated at 5) and detailing
| A National Clinical Guideline | Management of an Acute Asthma Attack in Adults
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the external review process (item 13 rated at 5); while these 2 items were reported the details
were limited and did not meet all the criteria/considerations outlined in AGREE II.

Figure 3 Group consensus appraisal scores for the BTS/SIGN Guideline

Figure 4 Group consensus appraisal scores for the GINA Guideline

Drawing on the AGREE II instrument the 6 domain scores are independent and should not be
aggregated into a single quality score; rather a quality score is calculated for each of the 6
AGREE II domains. The appraisal group’s consensual quality scores for each of the 6 AGREE II
domains for both BTS/SIGN (8) and GINA (14) guidelines are displayed in Table 3 below. While
these domain scores may be useful in comparing the guidelines the AGREE Consortium has
not set minimum domain scores or patterns of scores across domains to differentiate between
high and low quality but rather recommends that decisions are made by users and guided
by the context in which AGREE II is used (12). On completing the 23 items of the AGREE II, 2
overall assessments of the guideline were made. One required the appraiser to make an overall
judgement on the quality of the guideline and the other asked the appraiser whether he/she
would recommend the guideline for use. The consensus of the guideline appraisal group was
that they would recommend both BTS/SIGN (8) and GINA (14) for use and the overall judgement
on the quality of both BTS/SIGN (8) and GINA (14) is presented in Figure 5 below where a rating of
1 represents ‘lowest possible quality’ whereas a rating of 7 represents ‘highest possible quality’.
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Table 3 Quality Score for each six AGREE II domains for both BTS/SIGN (8) and GINA (14)
Guideline/ Domain 1: Domain 2: Domain 3: Domain 4: Domain 5: Domain 6:
Domain Scope & Stakeholder Rigour of Clarity of Applicability Editorial
Purpose Involvement Development Presentation Independence

BTS/SIGN 21/21 20/21 56/56 21/21 17/28 14/14


100% 95% 100% 100% 61% 100%

GINA 18/21 16/21 51/56 20/21 20/28 14/14


86% 76% 91% 95% 71% 100%

Figure 5 Rating of overall quality of the guideline

1.7.6 Strand 3: Analysis of guideline recommendations


For this strand steps 13, 14 and 15 of the ADAPTE process were drawn upon which included
assessing the content and consistency of the guidelines, in addition to, the acceptability and
applicability of the recommendations.

Assessing guideline content


Drawing on the example in the ADAPTE guidelines, a tabulated matrix to extract
recommendations from the guidelines under review was designed. Data on the context/topic,
key recommendation and grade of evidence was extracted. In relation to what context/topic
and key recommendations to extract, this was guided by the overall review objective and the
pre-determined PICO parameters. Thus, recommendation data was extracted that specifically
referred to “acute” asthma management in adults. This resulted in the exclusion of a large
proportion of recommendations from both guidelines which largely focused on the general
principles of controlling, monitoring, treating (pharmacologically and non-pharmacologically)
and reducing modifiable risks in the management of stable asthma. Content recommendations
related to children or youth populations, difficult or severe but stable asthma, or
recommendations related to specific setting such as primary care and/or populations such
as pregnant women were not extracted unless explicit reference was made to management
of “acute asthma exacerbations/asthma attack” in such settings/populations. This left a very
definite set of extracted recommendations on the management of “acute asthma in adults”
including referral for admission, pharmacological treatments for acute asthma in adults,
investigations and monitoring, treating modifiable risks to reduce attacks, acute management
in pregnancy, primary care, emergency departments and supporting self-management at time
and following an acute exacerbation/asthma attack.
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Only graded evidence based recommendations were extracted. It is worth noting that there
were some subtle differences in the criteria descriptions that each guideline used in grading the
recommendations and for ease of comparison these are presented in Appendix 11. A particular
point to note when reviewing the extracted recommendations is that the BTS/SIGN guideline (8)
refers to the levels of evidence as GRADES A-D, whereas the GINA guideline (14) uses the word
EVIDENCE to distinguish levels of evidence A-D. Initially, recommendations for each guideline
were extracted into two separate matrixes independently by one review team member – BTS/
SIGN and GINA . These data extraction matrixes were then collated into one matrix combining
the context/topic areas and recommendations from both guidelines (BTS/SIGN and GINA);
however, apart from ‘acute asthma management in pregnancy’ there was limited overlap
on the context/topic areas of the recommendations. All matrixes were cross-checked by
a 2nd reviewer. Discrepancies were resolved by a 3rd reviewer and discussed with the Clinical
Effectiveness Unit (CEU) and the Health Service Executive (HSE) Asthma Guideline Development
Group (GDG). This included; discussions around the applicable recommendations to extract
from the eligible guidelines i.e. recommendations had to be supported by graded evidence
and recommendations had to be specifically related to ‘acute asthma management in adults’.
Following discussions, the recommendation data extraction table was revised as presented in
Appendix 12.

Assessing consistency between evidence, interpretation and recommendations


The assessment of consistency between evidence, interpretation and recommendations was
conducted and cross-checked by 2 members of the review team with discrepancies resolved
through discussion with a 3rd reviewer. To do this, firstly tool 13 from the ADAPTE process was
used to evaluate the guideline search strategy and selection of evidence (i.e. relevance
and exhaustiveness of databases searched, search strategies used, methods, criteria for
selection of evidence, references etc.). Secondly, to evaluate the consistency between the
selected evidence, its interpretation and resulting recommendation, access to evidence
tables was sought. Where evidence was reported as weak or non-existent for a suggested
recommendation explicit indication of the basis for the recommendation was sought (i.e. based
on expert consensus). We drew on the ADAPTE process in relation to questions to ask in this
evaluation (ADAPTE p. 31) and used the evaluation sheet for determining the scientific validity
of guidelines (tool 14 ADAPTE).

The reviewer consensus ratings for Tool 13 (ADAPTE process) are presented in Appendix 13.
Tool 13 evaluates the search and selection of evidence. There was agreement among the 2
reviewers that the overall search for evidence was comprehensive for both the BTS/SIGN (8) and
GINA guideline (14). Tool 13 also evaluates reviewer’s judgement on the bias in the selection of
articles. For both the BTS/SIGN (8) and GINA (14) guideline, both reviewers found this difficult to
assess but were in agreement in their rating of ‘unsure’; this was as a consequence of limited
reporting of the selection process in relation to the explicit number of references analysed,
included, excluded and reasons for exclusion etc. While it was clear that explicit methodological
processes were followed (17) in the selection and screening of evidence the actual outcomes
were not reported explicitly in the guideline document to make adequate judgements on
whether the overall bias in the selection of articles was avoided.

The reviewer consensus ratings for Tool 14 (ADAPTE process) are presented in Appendix 14.
Tool 14 (ADAPTE process) evaluates 3 elements; whether the overall evidence is considered
valid; whether the evidence and recommendations are coherent; and whether the scientific
quality of the recommendations pose any risk of bias. For both the BTS/SIGN (8) and GINA (14)
guideline, both reviewers agreed that the overall evidence was valid, the evidence presented
throughout both guideline documents was mapped coherently to the recommendations and
overall it was agreed the scientific quality of the recommendations of both the BTS/SIGN (8) and
GINA (14) guidelines did not present risks of bias with the strength of the evidence attributed
to each recommendation being adequately described, justified and clearly presented in both
guidelines. Refer to Appendix 14.
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Assessing acceptability and applicability of guideline recommendations


This phase was undertaken to determine the applicability of the guideline recommendations for
inclusion in the Irish National Clinical Guideline for the Management of an Acute Asthma Attack
in Adults. For acceptability and applicability the guideline recommendations were assessed by
using the ADAPTE acceptability/applicability worksheet (tool 15) related to acute adult asthma
management. This was conducted and cross-checked by 2 members of the review team with
discrepancies resolved through discussion with a 3rd reviewer. The reviewer consensus ratings for
Tool 15 (ADAPTE process) are presented in Appendix 15. Tool 15 evaluates whether the overall
recommendations for the management of acute asthma in adults were acceptable and
applicable. There was a general consensus among reviewers that all recommendations were
acceptable and applicable for consideration in the Irish context by the Guideline Development
Group.

1.7.7. Concluding summary


Using a systematic approach to searching, screening and appraisal, this review has identified a
number of evidence based recommendations for the Guideline Development Group to consider
in relation to the management of an acute asthma attack in adults. These recommendations
were drawn from two guidelines BTS/SIGN (8) and GINA (14) and are outlined in Appendix 12.
The total recommendations extracted from both guidelines were in excess of 50 and spanned
all grades of evidence A-D including good practice points based on clinical experience/
panel consensus judgement; these are clearly highlighted in Appendix 12. The findings of this
review should be viewed alongside the following limitations. The possibility that the search
did not identify all relevant clinical guidelines cannot be excluded and inclusion of guidelines
only in the English language may have introduced a degree of bias as a consequence of the
exclusion of guidelines from different cultural contexts. These limitations were somewhat offset,
however, by the use of explicit inclusion criteria, PICOs and a broad search strategy, inclusive of
grey literature, guideline databases, guideline developer websites and a large cross-section of
asthma, thoracic and lung associations. The fact that all searches and screening, conducted
independently by at least 3 reviewers, consistently arrived at both the BTS/SIGN (8) and GINA
(14) clinical guidelines increased our confidence that all relevant and current guidelines
were identified for the review specified time period of 2011-2015. In relation to the appraisal
process, the appraisal of both the BTS/SIGN (8) and GINA (14) guidelines was based solely on
the “reporting” within the guidelines and thus might not accurately reflect the actual guideline
development process; however, due to short timelines the authors/guideline developers
were not contacted for additional clarification of unclear/missing information in relation to
methodological processes. Arguably, this could also have accounted for lower scores for the
applicability domain for both BTS/SIGN (8) and GINA (14) guideline quality appraisals as such
information around planning, undertaking and evaluating implementation is more likely found
outside the guideline document itself rendering the assessment of the applicability domain
more challenging – this is something that has been highlighted recently in the literature (18).
While the scoring of the AGREE II instrument can be a subjective process, the use of MY AGREE
PLUS to coordinate the group quality appraisal assisted all four quality appraisal reviewers to
independently appraise and comment on each appraisal item/domain before any group
discussion to reach consensus was made thereby enhancing transparency in our audit trail
and decision-making process. The consensus of the guideline appraisal group was that they
would recommend both the BTS/SIGN (8) and GINA (14) guideline for use with an overall quality
judgement rating of 7 and 6 attributed to the BTS/SIGN (8) and GINA (14) guideline respectively
(where a rating of 1 represents ‘lowest possible quality’ whereas a rating of 7 represents ‘highest
possible quality’).
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1.8 Grading of recommendations


This evidence-based clinical practice guideline, based on the highest quality scientific evidence
available, is a systemically developed statement containing recommendations for healthcare
professions on the care of individuals with asthma. Guidelines are not intended to replace the
healthcare professional’s expertise or experience but are a tool to assist practitioners in their
clinical decision-making process, with consideration for their patient’s preferences.

To assist the reader of this guideline, the key to the grading of evidence and recommendations
is as follows:

Levels of evidence

1++ High quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias

1+ Well conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias

1- Meta-analyses, systematic reviews, or RCTs with a high risk of bias

2++ High quality systematic reviews of case control or cohort studies


High quality case control or cohort studies with a very low risk of confounding or bias and a high
probability that the relationship is causal

2+ Well conducted case control or cohort studies with a low risk of confounding or bias and a
moderate probability that the relationship is causal

2 Case control or cohort studies with a high risk of confounding or bias and a significant risk that
the relationship is not causal

3 Non-analytic studies, eg case reports, case series

4 Expert opinion

Grades of recommendation

Note: The grade of recommendation relates to the strength of the evidence on which the
recommendation is based. It does not reflect the clinical importance of the recommendation.

A At least one meta-analysis, systematic review, or RCT rated as 1++, and directly applicable to
the target population; or body of evidence consisting principally of studies rated as 1+, directly
applicable to the target population, and demonstrating overall consistency of results

B A body of evidence including studies rated as 2++, directly applicable to the target population,
and demonstrating overall consistency of results; or Extrapolated evidence from studies rated
as 1++ or 1+

C A body of evidence including studies rated as 2+, directly applicable to the target population
and demonstrating overall consistency of results; or Extrapolated evidence from studies rated
as 2++

D Evidence level 3 or 4; or Extrapolated evidence from studies rated as 2+


| Management of an Acute Asthma Attack in Adults | A National Clinical Guideline
24 (aged 16 years and older)

Good practice points

√ Recommended best practice based on the clinical experience of the guideline development group

Grading of evidence and recommendations

Recommendations within this guideline are based on the best clinical evidence.

1.9 External review


The GDG sought the assistance of an International asthma advisor to review the draft guideline
document - Prof. Mark Fitzgerald, Professor of Medicine, Head, University of British Columbia
and Vancouver General Hospital Divisions of Respiratory Medicine, Director, Centre for Lung
Health, The Lung Centre, Vancouver, Canada and Chairman of Scientific Committee GINA.
Prof. Mark Fitzgerald was selected as an external reviewer due to his expertise in asthma care
and for his broad international experience in asthma guideline development and guideline
implementation in Canada.

This guideline was reviewed in draft form by Prof. Fitzgerald as an independent expert referee,
who was asked to comment primarily on the comprehensiveness and accuracy of interpretation
of the evidence base supporting the guideline and recommendations. Prof. Fitzgerald
agreed with the guideline contents without significant changes. Prof. Fitzgerald’s most recent
declarations of interest are available on www.ginasthma.org.

1.10 Procedure for update of National Clinical Guideline


This guideline was published in November 2015 and will be reviewed in 3 years by the NCPA.
Surveillance of the literature base will be carried out periodically by the NCPA so that the
guideline will maintain its relevance and currency. Any updates to the guideline in the interim
period or as a result of three year review will be subject to the NCEC approval process and
noted in the guidelines section of the NCPA and NCEC websites.

1.11 Implementation of National Clinical Guideline


The implementation of the guideline will take multiple routes and will be a phased approach
over a two to three year period.

All hospitals admitting asthma attacks should adopt this standard treatment protocol for the
management of the asthma patient. The treatment care bundles, presented in Appendix 2,
should be held in the patients chart. The care bundles are key to the evaluation and audit of
asthma care process.

These protocols should be adopted by all hospitals who may deal with an asthma attacks in
the course of other procedures, interventions, day surgery, admission, in-patient and out-patient
visits.

A local implementation team with a local lead in each hospital site will facilitate implementation
of the programme and these guidelines. This local lead will act as a champion for the
programme. Whilst this group is not active in each site currently, the NCPA will untertake to
engage with each site to support the establishment and ongoing activities of this group.
| A National Clinical Guideline | Management of an Acute Asthma Attack in Adults
(aged 16 years and older) 25

General Practitioners managing acute asthma attacks in primary care should adopt this
standard treatment protocols and bundles for the management of the asthma patient.

1.11.1 Facilitation of implementation


To facilitate the implementation of the guideline, an asthma education programme has been
developed and is available online (www.asthmasociety.ie and www.hse.ie). In addition a
half day training workshop is provided by respiratory Clinical Nurse Specialists. The training
workshop has recieved Category 1 approval from the Nursing and Midwifery Board of Ireland
(NMBI). Medical/nursing training, undergraduate, post graduate and continuous professional
development courses will be updated regularly in line with guidelines. Further training initiatives
are underway in primary care for the implementation of national ICGP Quality in Practice
Committee asthma guidelines.

The eLearning programme has been approved for CPD credits by ICGP.

The ICGP have developed additional online asthma modules to complement the NCPA
programme. This is recommended for all primary care physicians and physicians-in-training.

1.11.2 Potential barriers to implementation


A barrier to implementation will be a lack of appropriate knowledge and training amongst
heathcare professionals in the undertaking of an acute asthma assessment and in the provision
of care. Healthcare professionals at every step of the patients‘ journey during an acute asthma
attack should adhere to this guideline and register for relevant training (as set out in section
1.11.1 above) if required. The NCPA will work in collaboration with other key stakeholders to raise
awareness and promote the use of this guideline.

It is well documented worldwide that patients with asthma have low expectations of disease
management. They are frequently unaware of the GINA definition of well-controlled asthma
and thus believe that daily wheezing/frequent need for short acting beta 2 agonist (SABA) is
‘normal’. Thus, if patients’ expectations of asthma management remain unchanged they will
not be receptive to training on inhaler technique, education on medication adherence, use of
an asthma action plan etc. This is one of the major barriers to implementation and needs to be
addressed by all healthcare professionals. The introduction of the ‘Under 6s‘ medical card in the
GP under 6s contract in April 2015 is helping to address this issue as it includes an annual ‘Cycle
of Care’ for Asthma assessment and chronic disease management which reflects significant
elements of the Asthma Model of Care of the National Clinical Programme for Asthma. It is
anticipated that a similar approach will be developed for older children and adults asthma in
the near future.

1.12 Tools to assist the implementation of the National Clinical Guideline


A list of relevant tools to assist in the implementation of the National Clinical Guideline is
available in Appendix 2.

1.13 Roles and responsibilities

1.13.1 Local hospital services


The CEO/General Manager, the Clinical Director and the Director of Nursing of the hospital have
corporate responsibility for the implementation of this National Clinical Guideline and to ensure
that all relevant staff are appropriately supported and trained to implement the guideline.
| Management of an Acute Asthma Attack in Adults | A National Clinical Guideline
26 (aged 16 years and older)

All clinical staff with responsibility for the care of patients with asthma are expected to:
• Comply with this National Clinical Guideline and any related procedures or protocols,
• Adhere to their code of conduct and professional scope of practice as appropriate to their
role and responsibilities, and
• Maintain their competency for the management and treatment of patients with asthma.

1.13.2 Primary care services


Acute asthma care for each patient in primay care is generally the responsibility of the patient’s
GP, and when required, to link to the out of hours services in primary care (local on-call or the
GPOOH services)and to the acute hospital ED services when appropriate.

The roles and responsibilities of all stakeholders involved in the lifecycle of the guideline are
detailed in the table below (this is not an exhaustive list).

Table 4 Roles and responsibilities of stakeholders in relation to the National Clinical Guideline

Process Applying Auditing Use Developing/ Reviewing


Updating

General Practitioners 3
Practice Nurses 3
Out of Hours Staff 3
Pharmacist 3
Pre-Hospital emergency care 3
practitioners

ED/AMU Physicians 3
ED/AMU Nursing Staff 3
Specialist Respiratory Teams 3 3 3 3
Clinical Audit Services 3 3
National Clinical Programme for 3 3 3
Asthma

Pre-Hospital Emergency Care 3 3 3


Council

Patient Organisation 3
(Asthma Society of Ireland)
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(aged 16 years and older) 27

1.14 Audit criteria


To ensure that this guideline positively impacts on patient care, it is important that implementation
is audited. Audit is recommended to support continuous quality improvement in relation to the
implementation of the National Clinical Guideline.

The following Key Performance Indicators will be used to evaluate the implementation of the
guideline:
• Percentage of nurses in primary and secondary care who are trained by the National
Asthma Programme
• Number of deaths caused by asthma annually

As the process of implementation continues the National Clinical Programme for Asthma will
endeavour to expand the audit criteria.

At a local level, audit of the use of the treatment protocols will be carried out by Emergency/
Acute Medicine / Respiratory teams. The ED, AMU, Medical ward will retain a copy of the
treatment bundle administered on file and make a copy available to assist them with audit. This
will serve a dual function:

1) Notification of the patient to the Respiratory service for follow-up;


2) Audit of the treatment and education supplied to the patient prior to discharge.

1.15 Unlicensed medicines


It is important to recognise that the licensing process for drugs regulates the marketing activities
of pharmaceutical companies, and not prescribing practice. Unlicensed use of drugs by
prescribers is often appropriate and guided by clinical judgement. This practice is safeguarded
in legislation in accordance with Medicinal Products (Control of Placing in the Market)
Regulations 2007 (S.I. 540/2007) as amended. Furthermore, drugs prescribed outside license can
be dispensed by pharmacists and administered by nurses or midwives.

This note should be read alongside Recommendations 16 and 18 and their preceding texts.
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28 (aged 16 years and older)

2 National Clinical Guideline recommendations

2.1 Summary of national recommendations.


The CEO/General Manager, the Clinical Director and the Director of Nursing of the hospital have
corporate responsibility for the implementation of the recommendations in this National Clinical
Guideline. Each member of the multidisciplinary team is responsible for the implementation of
the individual guideline recommendations relevant to their discipline.

Risk Factors for Developing Fatal Asthma


Grade Recommendation

1. Healthcare professionals must be aware that patients who present with a severe asthma
B
attack and one or more adverse psychosocial factors are at risk of death.

Management of Acute Asthma In Adults


Hospital Referral/Admission

B 2. Clinicians in primary and secondary care should treat asthma attacks according to
recommended guideline.

B 3. Refer patients to hospital who display any features of acute severe or life threatening asthma.

B 4. Admit patients to hospital with any feature of a life threatening or near fatal attack.

B 5. Admit patients to hospital with any feature of a severe attack persisting after initial treatment.

C 6. Admit patients to hospital whose peak flow is less than 75% best or predicted after initial
treatment.

C 7. Patients whose peak flow is greater than 75% best or predicted one hour after initial treatment
may be discharged from ED unless they meet any of the following criteria, when admission
may be appropriate:
• still have significant symptoms
• concerns about adherence
• living alone/socially isolated
• psychological problems
• physical disability or learning difficulties
• previous near-fatal asthma attack
• asthma attack despite adequate dose steroid tablets pre-presentation
• presentation at night
• pregnancy.
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(aged 16 years and older) 29

Treatment of Acute Asthma

OXYGEN β2 Agonist Bronchodilators

C 8. Give supplementary oxygen to all A 11. Adults with mild and moderate attacks
hypoxaemic patients with acute of asthma should be treated by pMDI +
asthma to maintain an SpO2 level spacer with doses titrated according to
of 94-98%. Lack of pulse oximetry clinical response.
should not prevent the use of A 12. In hospital, ambulance and primary care,
oxygen. nebulised β2 agonist bronchodilators should
A 9. In hospital, ambulance and preferably be driven by oxygen.
primary care, nebulised β2 agonist A 13. Consider continuous nebulisation in patients
bronchodilators should be driven with severe asthma who respond poorly to
by oxygen. an initial bolus dose of β2 agonist, using an
C 10. The absence of supplemental appropriate nebulizer.
oxygen should not prevent A 14. In acute asthma with life threatening
nebulised β2 agonist therapy being features the nebulised route (oxygen-
given if indicated. driven) is recommended.
A 15. Use high dose inhaled β2 agonists as first line
agents in acute asthma and administer as
early as possible. Reserve intravenous β2
agonists for those patients in whom inhaled
therapy cannot be used reliably.

Steroid Therapy Ipratropium Bromide

A 16. Give steroids in adequate doses in B 17. Add nebulised ipratropium bromide (0.5
all cases of acute asthma. mg 4-6 hourly) to β2 agonist treatment
for patients with acute severe or life
3 Continue oral prednisolone 40mg daily threatening asthma or those with a poor
for at least 5 days or until recovery. initial response to β2 agonist therapy.

IV magnesium, antibiotic use, Heliox

B 18. Consider giving a single dose of IV magnesium sulphate for patients with:
• Acute severe asthma who have not had a good initial response to inhaled
bronchodilator therapy
• Life threatening or near fatal asthma.

3 IV Magnesium sulphate (1.2 - 2g IV infusion over 20 minutes) should only be used following
consultation with senior medical staff.

B 19. Routine prescription of antibiotics is not indicated for patients with acute asthma.

B 20. Heliox is not recommended for use in acute asthma outside a clinical trial setting.
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Referral/Admission to the Intensive Care Unit (ICU) for Acute Asthma

B 21. Refer any patient:


• Requiring ventilator support
• With acute severe or life threatening asthma, failing to respond to therapy, evidenced
by:
- Deteriorating PEF
- Persisting or worsening hypoxia
- Hypercapnea
- ABG analysis showing 6 pH or 5 H+
- Exhaustion, feeble respiration
- Drowsiness, confusion, altered conscious state
- Respiratory arrest.

C 22. All patients transferred to intensive care units should be accompanied by a doctor suitably
equipped and skilled to intubate if necessary.

3 Patients with acute asthma should not be sedated unless this is to allow anaesthetic or intensive
care procedures.

Acute Asthma in Pregnancy

C 23. Give drug therapy for acute asthma as for the non-pregnant patient including systemic
steroids and magnesium sulphate.

D 24. Deliver high flow oxygen immediately to maintain oxygen saturation between 94-98%.

Discharge from Hospital

A 25. Discharge from hospital or ED should be a planned, supervised event which includes self-
management planning. It may safely take place as soon as clinical improvement is apparent

A 26. Prior to discharge, in patients should receive written personalised action plans, given by
clinicians with expertise in asthma management

B 27. Prescribe inhalers only after the patient has received training in the use of the device and
has demonstrated satisfactory technique

A 28. All people attending hospital with acute attacks of asthma should be reviewed by a
clinician with particular expertise in asthma management, preferably within 30 days

2.2 National recommendations

2.2.1 Risk factors for developing fatal asthma


Confidential enquiries into asthma deaths or near fatal asthma attacks from the UK and Ireland
have identified a number of factors which contribute to an asthma death. Most deaths from
asthma occur before admission to hospital, and usually occur in patients who have chronic
asthma, who are on inadequate inhaled corticosteroid therapy with increased reliance on
inhaled β2 agonists (10). There is generally poor perception by the patient or physician caring
for the patient of the overall severity of the asthma exacerbation. In addition, inadequate
management in the acute event, including using sedation in some cases, are also factors linked
to asthma deaths. Deaths from asthma while uncommon are generally preventable and occur
usually in association with an acute attack. Although most of these patients have chronically
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severe asthma, in a minority the fatal attack has occurred suddenly in a patient with mild or
moderately severe background disease. Most asthma deaths occur before admission to hospital.
Many deaths occur due to patients receiving inadequate treatment with inhaled steroids or
steroid tablets and/or inadequate objective monitoring of their asthma, where follow up was
inadequate in some and others should have been referred earlier for specialist advice (10).
Level of evidence 2++ (BTS/SIGN 2014)

Risk factors for developing fatal asthma include:


A combination of severe asthma recognised by one or more of:
• previous near-fatal asthma, e.g. previous ventilation or respiratory acidosis
• previous admission for asthma especially if in the last year
• requiring three or more classes of asthma medication
• heavy use of β2 agonist
• repeated attendances at ED for asthma care especially if in the last year

AND adverse behavioural or psychosocial features recognised by one or more of:


o non-adherence with treatment or monitoring
o failure to attend appointments
o fewer GP contacts
o frequent home visits
o self discharge from hospital
o psychosis, depression, other psychiatric illness or deliberate self harm
o current or recent major tranquilliser use
o denial
o alcohol or drug abuse
o obesity
o learning difficulties
o employment problems
o income problems
o social isolation
o childhood abuse
o severe domestic, marital or legal stress

“Studies comparing near-fatal asthma with deaths from asthma have concluded that patients
with near-fatal asthma have identical adverse factors to those described above and that
these contribute to the near-fatal asthma attack. Compared with patients who die, those with
near-fatal asthma are significantly younger, are significantly more likely to have had a previous
near-fatal asthma attack, are less likely to have concurrent medical conditions, are less likely
to experience delay in receiving medical care, and more likely to have ready access to acute
medical care.”
Level of evidence 2+ (BTS/SIGN 2014)

“With near-fatal asthma it is advisable to involve a close relative when discussing future
management.” (BTS/SIGN 2014)

Good practice point


√ Keep patients who have had a near-fatal asthma attack under specialist supervision indefinitely

All personnel who may be in contact with a patient with an acute asthma attack e.g. GP
practice receptionists, pre-hospital emergency care practitioners and responders, out of hours
staff and community pharmacists, should be aware that asthma patients complaining of
respiratory symptoms may require immediate access to a physician or a nurse trained in acute
asthma management as they may deteriorate suddenly.
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Patients’ with asthma should have an agreed guided written asthma management plan - this
can be disscussed during the follow-up after discharge. They should know when and how to
increase their medication and when to seek medical assistance if their asthma is not controlled.
Agreed treatment steps should be clearly illustrated within the written asthma management
plan. Such plans can decrease acute asthma, hospitalisation and deaths from asthma.

Responsibility recommendation 1: All healthcare professionals


Recommendation 1: Healthcare professionals must be aware that patients who present with a severe
asthma attack and one or more adverse psychosocial factors are at risk of death
Grade: B

2.2.2 Management of acute asthma attacks


What is best practice management of patients with an acute asthma attack in primary care?
Patients with asthma including all patients with severe asthma should have an agreed
written asthma management plan, with regular checks of inhaler technique and medication
compliance at every clinical assessment with the healthcare system.

Patients should know when and how to increase their medication and when to seek medical
assistance. This should be contained within the written asthma management plan with treatment
steps clearly illustrated. Such plans can decrease hospitalisation for and deaths from asthma.

De-escalating treatment steps must also be outlined in management plan once acute episode
is resolved.

All personnel who may be in contact with a patient with an acute asthma attack e.g. GP
practice receptionists, pre-hospital emergency care practitioners and responders, out of hours
staff and community pharmacists, should be aware that asthma patients complaining of
respiratory symptoms should have immediate access to a physician or a nurse trained in acute
asthma management as they may deteriorate rapidly.

“The assessments required to determine whether the patient is suffering from an acute attack
of asthma, the severity of the attack and the nature of treatment required are detailed in this
guideline. It may be helpful to use a systematic recording process. Proformas such as protocols
and care bundles in Appendix 2 have proved useful in acute asthma management”
(BTS/SIGN 2014)

The vast majority of acute asthma attacks are managed at Primary Care level including GP Out
of Hours (GPOOH) settings. These attacks are characterised by worsening symptoms including
shortness of breath, cough, wheezing or chest tightness, or a combination of these symptoms.

Factors which may increase the likelihood of an attack include:


• Non adherence with regular asthma therapy
• Failure to attend for regular follow up after an attack
• Self discharge from hospital following an attack
• Psychological issues
• Drug/Alcohol abuse
• Obesity
• Learning difficulties
• Social issues
(BTS/SIGN 2014)
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Some key points when dealing with an attack include:


• Take a good history from the patient in order to:
o Identify when symptoms started?
o How have symptoms progressed?
o What therapy has the patient taken to deal with asthma symptoms to date?
o Has a similar episode occurred in the past

It is important to be aware that patient’s symptoms may underestimate the severity of the attack
and to have objective measurements of the event, to include:
• Peak expiratory flow (PEF) or FEV1
• Respiratory rate
• Heart rate
• Oxygen saturation (when available)

The severity of asthma exacerbation can be categorised according to the algorithms included
in this guideline (see Appendix 2).

Good practice point


√ Ongoing education of GP practice staff in dealing with acute asthma should be in place. This involves
doctors, nurses and practice reception/telephone staff to ensure that patients with asthma are offered
prompt appointments.

√ GP support is required to allow patients who are seen in an acute event to be followed up and offered
structured care and education. This may involve making contact per phone or flagging notes when
patient attends again for any reason including repeat prescriptions.

What are the criteria for referral to the Emergency Department for patient with an acute asthma
attack?

Always dial 999/112 if:


• Symptoms persist
• No immediate improvement in symptoms after initial treatment or within 5 minutes after
treatment
• Too breathless or exhausted to talk
• Lips turn blue
• Or if in doubt

Most deaths from asthma occur before admission to hospital.

Protocols for the emergency treatment of asthma attacks in the pre-hospital setting can be
found on the Pre-Hospital Emergency Care Council (PHECC), www.phecc.ie, and are replicated
in Appendix 2.

What are the Hospital Admission Criteria with an acute asthma attack?

Criteria for admission


“Adult patients with any feature of a life-threatening or near-fatal asthma attack or a severe
asthma attack that does not resolve after initial treatment should be admitted to hospital.
Admission may also be appropriate when peak flow has improved to greater than 75% best or
predicted one hour after initial treatment but concerns remain about symptoms, previous history
or psychosocial issues.” (BTS/SIGN 2014)
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34 (aged 16 years and older)

Admit patients with any feature of a life-threatening or near-fatal asthma attack.

Admit patients with any feature of a severe asthma attack persisting after initial treatment.

Patients whose peak flow is greater than 75% best or predicted one hour after initial treatment
may be discharged from ED unless they meet any of the following criteria, when admission may
be appropriate:
• still have significant symptoms
• concerns about adherence
• living alone/socially isolated
• psychological problems
• physical disability or learning difficulties
• previous near-fatal asthma attack
• asthma attack despite adequate dose steroid tablets pre-presentation
• presentation at night
• pregnancy.
(BTS/SIGN 2014)

Asthma attacks (attacks of acute asthma) are associated with progressive increase in
asthma symptoms (typically, shortness of breath (SOB), cough, wheeze, chest tightness or any
combination of these) but the patient’s own perception of asthma symptoms in some cases
may be poor and thus unreliable. In addition to symptoms there is usually an objective decrease
in expiratory flow rates on lung function testing. This should be quantified by PEF or spirometry
(FEV1). The PEF or FEV1 expressed as percentage (%) of personal best is the most useful clinically
but in the absence of this the % predicted value is a rough guide. Of note a reduction to 50% or
less from predicted or best values indicates a severe attack. Pulse oximetry can be of use as low
oxygen levels may indicate the necessity for referral to hospital but normal levels greater than
92% do not exclude a severe asthma attack. These measures along with history, examination,
pulse and respiratory rate and response to treatment are all required to determine the need for
hospitalisation or risk of relapse after acute management. The assessment and management
should follow the guidelines outlined in the following acute asthma management protocols.

The SEVERITY evaluation of an attack is important and should be determined as to whether it


is mild, moderate, severe or life-threatening. Severe or life-threatening attacks require close
observation and should be referred to an Emergency Department (ED). Patients with life
threatening features at any time during the initial assessment in ED should be admitted to
hospital for at least 24 hours. In addition, patients with severe features persisting after the first
salbutamol nebulisation should be considered for admission until stable.

Patients at high risk of asthma deaths include those with:


• History of near fatal asthma requiring intubation and mechanical ventilation
• Hospital admission or ED attendance in past year
• Those using or recently stopped oral steroids
• Over use of β2 agonists (more than 1 inhaler per month)
• Psychiatric disease or psychosocial problems including sedative use
• History on non-compliance with asthma medication plan.

Recognition of acute asthma is done by assessing the level of severity of the patient and this
includes the clinical history, examination, (including chest, pulse and respiration rates), peak
flow rates (PEF) with peak flow meter and oxygen saturation (SpO2) with a pulse oximeter.
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Responsibility recommendation 2: Clinicians in primary and secondary care


Recommendation 2: Clinicians in primary and secondary care should treat asthma exacerbations
according to recommended guidelines.
Grade: B

Responsibility recommendation 3: General practitioners


Recommendation 3: Refer patients to hospital who display any features of acute severe or life threatening
asthma.
Grade: B

Responsibility recommendation 4: Clinicians


Recommendation 4: Admit patients to hospital with any feature of a life threatening or near fatal attack.
Grade: B

Responsibility recommendation 5: Clinicians


Recommendation 5: Admit patients to hospital with any feature of a severe attack persisting after initial
treatment.
Grade: B

Responsibility recommendation 6: Clinicians


Recommendation 6: Admit patients to hospital whose peak flow is less than 75% best or predicted
Grade: C

Responsibility recommendation 7: Clinicians


Recommendation 7: Patients whose peak flow is greater than 75% best or predicted one hour after initial
treatment may be discharged from ED unless they meet any of the following criteria, when admission
may be appropriate:
• still have significant symptoms
• concerns about adherence
• living alone/socially isolated
• psychological problems
• physical disability or learning difficulties
• previous near-fatal asthma attack
• asthma attack despite adequate dose steroid tablets pre-presentation
• presentation at night
• pregnancy.
Grade: C

What are the signs to distinguish the severity of an asthma attack?


In acute asthma it is important to assess and record the level of severity as in the tables below.

Delay in treatment and under-dosing in an asthma attack can adversely affect outcomes. By
using objective measures, the level of asthma severity is less likely to be underestimated. This will
enable prompt treatment at the right dose to be effective.
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36 (aged 16 years and older)

Table 5 Levels of severity for adults


Level of Severity
Life Threatening Asthma Features
Peak Flow Rate (PEF) PEF <33% best or predicted
Oxygen Saturation (SpO2) SpO2<92%
Speech Unable to talk - Exhausted, confusion, or coma
Respiratory Examination Poor respiratory effort, silent chest, cyanosis
Pulse Bradycardia, arrhythmia
BP Hypotension
Severe Asthma Features
Life Threatening Features No life threatening features
Peak Flow Rate (PEF) PEF 33–50% best or predicted
Oxygen Saturation (SpO2) SpO2>92%
Speech Cannot complete sentence in one breath
Respiratory Examination Respiration Rate>25 breaths/min
Pulse Pulse Rate >110 beats/min
BP Normal
Moderate Asthma Features
Life Threatening Features No life threatening features
Peak Flow Rate (PEF) PEF between 50-75% best or predicted
Oxygen Saturation (SpO2) Greater than 92%
Speech Talks in phrases, and prefers to sit
Respiratory Examination Loud wheeze and respiratory rate less than 25 breaths/min
Pulse Mild tachycardia but less than 110 beats/min
BP Normal
Mild Asthma Feature
Life Threatening Features No life threatening features
Peak Flow Rate (PEF) Greater than 75% best or predicted
Oxygen Saturation (SpO2) Greater than 92%
Speech Talks in sentences and can lie down
Respiratory Examination Mild wheeze and respirations less than 25 breaths/min
Pulse Pulse is less than 100 beats/min
BP Normal

Clinical features
“Clinical features can identify some patients with severe asthma, e.g. severe breathlessness
(including too breathless to complete sentences in one breath), tachypnea, tachycardia, silent
chest, cyanosis, accessory muscle use, altered consciousness or collapse. None of these singly
or together is specific. Their absence does not exclude a severe attack.”
Level of evidence 2+ (BTS/SIGN 2014)

What are the key components of an objective assessment of an attack in the adult asthma
patient?
Pulse oximetry
Good clinical practice would support a measure of oxygen saturation (SpO2) with a pulse
oximeter to determine the adequacy of oxygen therapy and the need for arterial blood gas
(ABG) measurement. The aim of oxygen therapy is to maintain SpO2 94-98%. In hypoxic patients
it is important to consider alternative diagnosis e.g. Pneumothorax or pneumonia.

PEF or FEV1
“Measurements of airway calibre improve recognition of the degree of severity, the
appropriateness or intensity of therapy, and decisions about management in hospital or at
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(aged 16 years and older) 37

home. PEF or FEV1 are useful and valid measures of airway calibre. PEF is more convenient in
the acute situation. PEF expressed as a percentage of the patient’s previous best value is most
useful clinically. PEF as a percentage of predicted gives a rough guide in the absence of a
known previous best value. Different peak flow meters give different readings. Where possible
the same or similar type of peak flow meter should be used.”
Level of evidence 2+ (BTS/SIGN 2014)

Chest X-ray
“Good clinical practice suggests that a Chest X-ray is not routinely recommended in patients
with an asthma attack in the absence of:
• suspected pneumomediastinum or pneumothorax
• suspected consolidation
• life threatening asthma
• failure to respond to treatment satisfactorily
• requirement for ventilation”
Level of evidence 4 (BTS/SIGN 2014)

Blood gases
“Patients with SpO2 less than (<) 92% (irrespective of whether the patient is on air or oxygen)
or other features of life threatening asthma require ABG measurement. SpO2 less than 92% are
associated with a risk of hypercapnea (raised blood CO2). Hypercapnea is not detected by
pulse oximetry. In contrast the risk of hypercapnea with SpO2 greater than 92% is much less.”
Level of evidence 2+ and 4 (BTS/SIGN 2014)

What is the best practice treatment of the adult asthma patient during an acute attack?
The primary therapies for the management of an attack to relieve airflow obstruction and
hypoxemia include:
• Repetitive administration of rapid-acting inhaled β2 agonist bronchodilator via pMDI with
spacer or O2 driven nebuliser
• Early introduction of systemic glucocorticosteroids
• Oxygen supplementation
• (The clinician may decide if antibiotic therapy is appropriate in some cases)

Oxygen
“Many patients with acute severe asthma are hypoxemic (low blood oxygen). Supplementary
oxygen should be given urgently to hypoxemic patients, using a face mask, Venturi mask or
nasal cannula with flow rates adjusted as necessary to maintain SpO2 of 94-98%.” (BTS/SIGN
2014)

“Hypercapnea (raised blood CO2 levels) indicates the development of near-fatal asthma and
the need for emergency specialist/anaesthetic intervention”.
Level of evidence 2+, 4 (BTS/SIGN 2014)

Responsibility recommendation 8: General Practitioners, pre-hospital emergency care


practitioners, ED/AMU physicians, asthma specialists and nursing staff
Recommendation 8: Give supplementary oxygen to all hypoxaemic patients with acute severe asthma
to maintain SpO2 level of 94-98%. Lack of pulse oximetry should not prevent the use of oxygen.
Grade: C
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Responsibility recommendation 9: General Practitioners, pre-hospital emergency care


practitioners, ED/AMU physicians, asthma specialists and nursing staff
Recommendation 9: (see β2 agonist recommendations)
In hospital, pre-hospital emergency care and primary care, nebulised β2 agonist bronchodilators should
preferably be driven by oxygen.
Grade: A

Responsibility recommendation 10: General Practitioners, pre-hospital emergency care


practitioners, ED/AMU physicians, asthma specialists and nursing staff
Recommendation 10: (see β2 agonist recommendations)
The absence of supplemental oxygen should not prevent nebulised β2 agonist therapy being given if
indicated
Grade: C

β2 agonist bronchodilators – repeated administration of rapid-acting inhaled β2 agonist


“In most cases inhaled β2 agonists given in high doses act quickly to relieve bronchospasm with
few side effects. There is no evidence for any difference in efficacy between salbutamol and
terbutaline. Nebulised adrenaline (epinephrine), a non-selective β2 agonist, does not have
significant benefit over salbutamol or terbutaline.” (BTS/SIGN 2014)

In acute asthma without life threatening features, “β2 agonists can be administered by repeated
activations of a pressurised metered dose inhaler (pMDI) via an appropriate large volume spacer
or by wet nebulisation driven by oxygen, if available. Inhaled β2 agonists are as efficacious and
preferable to intravenous β2 agonists (meta-analysis has excluded subcutaneous trials) in adult
acute asthma in the majority of cases. Metered dose inhalers with spacers can be used for
patients with attacks of asthma other than life threatening” (BTS/SIGN 2014). The bronchodilator
therapy delivered via metered-dose inhaler pMDI, ideally with a spacer, produces at least an
equivalent improvement in lung function as the same dose delivered via nebulizer. This route
of delivery is the most cost effective, provided patients are able to use an pMDI with spacer
assistance.

Mild/Moderate attacks: give up to 12 puffs via spacer, one at a time and inhaled separately.
Assess after 10-20 minutes. Repeat as necessary (3 doses in total). No additional medication
is necessary if the rapid-acting inhaled β2 agonist produces a complete response (FEV1 or PEF
returns to greater than 80% of predicted or personal best) and the response lasts for 3 to 4 hours.

“Oxygen-driven nebulisers are preferred for nebulising β2 agonist bronchodilators because of


the risk of oxygen desaturation while using air-driven compressors”.
Level of evidence 1++ (BTS/SIGN 2014).

Emergency oxygen should be available in hospitals, ambulances and primary care.


“A flow rate of 6 litres/min is required to drive most nebulisers. Where oxygen cylinders are used,
a high flow regulator must be fitted.”
Level of evidence 4 (BTS/SIGN 2014)

“The absence of supplemental oxygen should not prevent nebulised therapy from being
administered when appropriate”.
Level of evidence 4 (BTS/SIGN 2014)

“Repeat doses of β2 agonists at 15-30 minute intervals or give continuous nebulisation of


salbutamol at 5-10 mg/hour (requires appropriate nebuliser) if there is an inadequate response
to initial treatment.” (BTS/SIGN 2014)
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“Parenteral β2 agonists, in addition to inhaled β2 agonists, may have a role in ventilated patients
or those in extremis; however there is limited evidence to support this”. (BTS/SIGN 2014)

“Most cases of acute asthma will respond adequately to bolus nebulisation of β2 agonists.
Continuous nebulisation of β2 agonists with an appropriate nebuliser may be more effective than
bolus nebulisation in relieving acute asthma for patients with a poor response to initial therapy”.
Level of evidence 1+ (BTS/SIGN 2014)

“In acute asthma without life threatening features, β2 agonists can be administered by repeated
activations of a pMDI via an appropriate large volume spacer or by wet nebulisation driven
by oxygen, if available. Inhaled β2 agonists are as efficacious and preferable to intravenous β2
agonists (meta-analysis has excluded subcutaneous trials) in adult acute asthma in the majority
of cases”.
Level of evidence: 1 ++ (BTS/SIGN 2014)

“Metered dose inhalers with spacers can be used for patients with attacks of asthma other than
life threatening.”
Level of evidence 1++ (BTS/SIGN 2014)

Responsibility recommendation 11: General Practitioners, pre-hospital emergency care


practitioners, ED/AMU physicians and nursing staff
Recommendation 11: Adults with mild and moderate exacerbations of asthma should be treated by
pMDI + spacer with doses titrated according to clinical response.
Grade: A

Responsibility recommendation 12: General Practitioners, pre-hospital emergency care


practitioners, ED/AMU physicians, asthma specialists and nursing staff
Recommendation 12:(see oxygen recommendation)
In hospital, pre-hospital emergency care and primary care, nebulised β2agonist bronchodilators should
preferably be driven by oxygen.
Grade: A

Responsibility recommendation 13: General Practitioners, pre-hospital emergency care


practitioners, ED/AMU physicians, asthma specialists and nursing staff
Recommendation 13: (see oxygen recommendation) Consider continuous nebulisation in patients with
severe asthma who respond poorly to an initial bolus dose of β2 agonist, using an appropriate nebuliser.
Grade: A

Responsibility recommendation 14: General Practitioners, pre-hospital emergency care


practitioners, ED/AMU physicians, asthma specialists and nursing staff
Recommendation 14: In acute asthma with life threatening features the nebulised route (oxygen-driven)
is recommended.
Grade: A
| Management of an Acute Asthma Attack in Adults | A National Clinical Guideline
40 (aged 16 years and older)

Responsibility recommendation 15: General Practitioners, pre-hospital emergency care


practitioners, ED/AMU physicians, asthma specialists and nursing staff
Recommendation 15: Use high dose inhaled β2 agonists as first line agents in acute asthma and administer
as early as possible. Reserve intravenous β2 agonists for those patients in whom inhaled therapy cannot
be used reliably.
Grade: A

Steroids (Glucocorticosteroids)
“Steroids reduce mortality, relapses, potential hospital admission and requirement for β2 agonist
therapy. The earlier they are given in the acute attack the better the outcome”.
Level of evidence 1++ (BTS/SIGN 2014)

Oral steroids (0.5 to 1 mg of prednisolone/kg or equivalent during a 24-hour period) should be


used to treat an attack, especially if they develop after instituting other short-term treatment
options recommended for loss of control. If the patient fails to respond to bronchodilator
therapy, as indicated by persistent airflow obstruction, prompt transfer to an acute care setting
is recommended, especially if they are in a high-risk group. Response to treatment may take
time. Patients should be closely monitored using clinical and objective measures. Response to
treatment should continue until measurements of lung function (FEV1 or PEF) return ideally to
previous best or plateau. Patients who can be safely discharged will have responded within the
first few hours.

“Steroid tablets are as effective as injected steroids, provided they can be swallowed and
retained. Oral prednisolone 40-50 mg daily or parenteral (IV) hydrocortisone 400 mg daily (100
mg six-hourly) is as effective as higher doses. For convenience, steroid tablets may be given as
2 x 25 mg tablets daily rather than 8 - 10 x 5 mg tablets. Where necessary soluble prednisolone
(sodium phosphate) 5 mg tablets can be used. In cases where oral treatment may be a problem
consider intramuscular (IM) methylprednisolone 160 mg as an alternative to a course of oral
prednisolone (this is likely to be a large 4mls injection).”
Level of evidence: 1++ (BTS/SIGN 2014)

“Following recovery from the acute attack steroids can be stopped abruptly. Good practice
indicates that doses do not need tapering provided the patient receives inhaled steroids
(caution is required for patients on maintenance steroid treatment or rare instances where
steroids are required for three or more weeks)”.
Level of evidence 1+ (BTS/SIGN 2014)

In addition to systemic (oral, IV, or IM) steroids, inhaled steroids should be continued (or started if
not already prescribed) and commence the chronic asthma management plan.
Level of evidence 1+ (BTS/SIGN 2014)

Responsibility recommendation 16: Clinicians


Recommendation 16: Give steroids in adequate doses in all cases of acute asthma
Grade: A

Good practice point


√ Continue oral prednisolone 40mg daily for at least 5 days or until recovery.

Ipratropium bromide
“Combining nebulised ipratropium bromide with a nebulised β2 agonist produces significantly
greater bronchodilation than a β2 agonist alone, leading to a faster recovery and shorter dura-
| A National Clinical Guideline | Management of an Acute Asthma Attack in Adults
(aged 16 years and older) 41

tion of admission. Anticholinergic treatment is not necessary and may not be beneficial in milder
attacks of asthma or after stabilisation”.
Level of evidence 1++ (BTS/SIGN 2014)

Responsibility recommendation 17: Clinicians


Recommendation 17: Add nebulised ipratropium bromide (0.5 mg 4-6 hourly) to β2 agonist treatment
for patients with acute severe or life threatening asthma or those with poor initial response to β2 agonist
therapy.
Grade: B

Magnesium sulphate
“There is some evidence that, in adults, magnesium sulphate has bronchodilator effects.” (BTS/
SIGN 2014). Experience suggests that magnesium is safe when given by the intravenous (IV) or
nebulised route. Trials comparing these routes of administration are awaited. Studies report the
safe use of nebulised magnesium sulphate, in a dose of 135 mg - 1152 mg, in combination with
β2 agonists, with a trend towards benefit in hospital admission. “A single dose of IV magnesium
sulphate is safe and may improve lung function in patients with acute severe asthma” (BTS/SIGN
2014).
Level of evidence 1++ (BTS/SIGN 2014)

“The safety and efficacy of repeated IV doses has not been assessed. Repeated doses could
cause hypermagnesaemia with muscle weakness and respiratory failure.” (BTS/SIGN 2014)
More studies are needed to determine the optimal route, frequency and dose of magnesium
sulphate therapy.

Responsibility recommendation 18: Asthma specialists


Recommendation 18: Consider giving a single dose of IV magnesium sulphate for patients with:
• Acute severe asthma who have not had a good initial response to inhaled bronchodilator theraphy
• Life threatening or near fatal asthma.
Grade: B

Good practice point


√ IV magnesium sulphate (1.2 - 2g IV infusion over 20 minutes) should only be used following consultation
with senior medical staff.

Intravenous (IV) aminophylline


This drug is generally not for routine use as it may potentially increase morbidity and delay
anaesthetic review.

Good practice indicates that it should only be given on the advice of a senior physician.

However, in acute asthma, “IV aminophylline is not likely to result in any additional
bronchodilation compared to standard care with inhaled bronchodilators and steroids. Side
effects such as arrhythmias and vomiting are increased if IV aminophylline is used.”
Level of evidence 1++ (BTS/SIGN 2014)

“Some patients with near-fatal asthma or life threatening asthma with a poor response to initial
therapy may gain additional benefit from IV aminophylline (5 mg/kg loading dose over 20
minutes unless on maintenance oral therapy, then infusion of 0.5-0.7 mg/kg/hr). Such patients
are probably rare and could not be identified in a meta-analysis of trials. If IV aminophylline
is given to patients on oral aminophylline or theophylline, blood levels should be checked on
| Management of an Acute Asthma Attack in Adults | A National Clinical Guideline
42 (aged 16 years and older)

admission. Levels should be checked daily for all patients on aminophylline infusions.” (BTS/SIGN
2014)

Leukotriene receptor agonist


There is some emerging evidence to suggest a possible role of montelukast (singulair) in acute
asthma but is insufficient currently to make a recommendation of its use in the management of
acute asthma.

Antibiotics
Antibiotics should not be given automatically unless there is strong suspicion of bacterial
infection, elevated temperature, raised white cell count, infiltrate on chest x-ray or copious
green phlegm and should be guided by local microbiology guidelines.

“When an infection precipitates an asthma attack it is likely to be viral. The role of bacterial
infection in an attack has been overestimated.”
Level of evidence 1++ (BTS/SIGN 2014)

Routine prescription of antibiotics is not indicated for acute asthma.

Responsibility recommendation 19: Clinicians and community pharmacists


Recommendation 19: Routine prescription of antibiotics is not indicted for acute asthma
Grade: B

Intravenous fluids
There are no controlled trials, observational or cohort studies of IV fluid regimes in acute asthma.
Good practice point
√ Some patients with acute asthma require rehydration and correction of electrolyte imbalance.
Hypokalaemia can be caused or exacerbated by β2 agonist and/or steroid treatment and must be
corrected. (BTS/SIGN 2014)

Heliox
“The use of heliox, (helium/oxygen mixture in a ratio of 80:20 or 70:30), either as a driving gas
for nebulisers, as a breathing gas, or for artificial ventilation in adults with acute asthma is not
supported on the basis of present evidence. A systematic review of ten trials (554 patients),
including patients with acute asthma, found no improvement in pulmonary function or other
outcomes in adults treated with heliox, although the possibility of benefit in patients with more
severe obstruction exists. Heliox requires the use of specifically designed or modified breathing
circuits and ventilators.”
Level of evidence 1++, 1+ (BTS/SIGN 2014)

Responsibility recommendation 20: Clinicians and nursing staff


Recommendation 20: Heliox is not recommended for use in acute asthma outside a clinical trial setting

Nebulized furosemide
“Although theoretically furosemide may produce bronchodilation, a review of three small trials
failed to show any significant benefit of treatment with nebulised furosemide compared to β2
agonists”.
Level of evidence; 1+ (BTS/SIGN 2014)
| A National Clinical Guideline | Management of an Acute Asthma Attack in Adults
(aged 16 years and older) 43

ICU/HDU
“Indications for admission to intensive care or high-dependency units include patients requiring
ventilator support and those with severe acute or life threatening asthma who are failing to
respond to therapy, as evidenced by:
• deteriorating PEF
• persisting or worsening hypoxia
• hypercapnea
• arterial blood gas analysis showing fall in pH or rising H+ concentration
• exhaustion, feeble respiration
• drowsiness, confusion, altered conscious state
• respiratory arrest.

Not all patients admitted to the Intensive Care Unit (ICU) need ventilation, but those with
worsening hypoxia or hypercapnea, drowsiness or unconsciousness and those who have had
a respiratory arrest require intermittent positive pressure ventilation. Intubation in such patients
is very difficult and should ideally be performed by an anaesthetist or ICU consultant” (BTS/
SIGN 2014). Treatment has to be adjusted periodically in response to worsening control, which
may be recognised by the minor recurrence or worsening of symptoms following treatment for
an attack, maintenance treatment can be resumed at previous levels unless the attack was
associated with a gradual loss of control suggesting chronic under treatment.
Level of evidence; 2+ (BTS/SIGN 2014)

Responsibility recommendation 21: Clinicians


Recommendation 21: Refer to the ICU any patient:
• Requiring ventilator support
• With acute severe or life threatening asthma, failing to respond to initial therapy, evidenced by:
- Deteriorating PEF
- Persisting or worsening hypoxia
- Hypercapnea
- ABG analysis showing 6 pH or 5 H+
- Exhaustion, feeble respiration
- Drowsiness, confusion, altered conscious state
- Respiratory arrest
Grade: B

Responsibility recommendation 22: Clinicians and nursing staff


Recommendation 22: All patients transferred to intensive care units should be accompanied by a doctor
suitably equipped and skilled to intubate if necessary
Grade: C

Good practice point


√ Patients with acute asthma should not be sedated unless this is to allow anaesthetic or intensive care
procedures
| Management of an Acute Asthma Attack in Adults | A National Clinical Guideline
44 (aged 16 years and older)

Non invasive ventilation


“A Cochrane review found only one trial, with 30 patients, on NIV which showed improvement
in hospitalisation rates, discharge from emergency departments and lung function. Larger RCTs
are needed to determine the role of NIV in treating patients with acute asthma”.
Level of evidence: 1++ (BTS/SIGN 2014)

Good practice point


√ NIV for acute asthma should only be considered in an ICU or equivalent clinical setting.

Structured proforma
“The use of structured proformas facilitates improvements in the process of care in emergency
departments and hospital wards and improves patient outcomes. The use of this type of
documentation can assist data collection aimed at determining quality of care and outcomes”.
Level of evidence: 2 + (BTS/SIGN 2014)

What is best practice management of an acute asthma attack in pregnancy?


“The management of acute asthma in pregnancy may be affected by concerns about harmful
effects of medications on the fetus” (BTS/SIGN 2014). However the maternal and fetal risks of
uncontrolled asthma are much greater than the risks from conventional asthma medications
and acute asthma remains an important cause of maternal mortality. The Confidential Enquiry
into Maternal Deaths 2006-2008 reported 5 maternal deaths from asthma (19).

The ultimate goal of asthma therapy in pregnancy is maintaining adequate oxygenation of


the fetus by preventing hypoxic episodes in the mother. It should be emphasised that it is safer
for pregnant women with asthma to be treated with medications than it is for them to have
ongoing asthma symptoms and attacks. Pregnant women with asthma should be counselled
regarding the importance of compliance with treatment during pregnancy to ensure good
asthma control. Inhaled corticosteroids are first-line controller therapy for persistent asthma
during pregnancy.

“Prednisolone is extensively metabolised in the placenta such that only 10% reaches the fetus”
(BTS/SIGN 2014). Steroid therapy in the first trimester may be associated with an increased risk
of oral clefts in the fetus. However, women should be advised that if required, the benefits of
treatment with oral steroids for asthma attacks outweigh the risks thereof.

It is important that treatment with steroids should not be withheld if indicated for the management
of an asthma attack because of pregnancy.

The inhaled short acting β2 agonist, salbutamol, is recommended rescue therapy for pregnant
women with asthma. No significant association has been demonstrated between major
congenital malformations or perinatal outcomes and exposure to short acting β2 agonists.

2.2.3 Management of acute asthma in pregnancy


1. Patients presenting to the Emergency Room in a Maternity Hospital with an acute asthma
attack should be assessed according to acute adult asthma guidelines.
2. Pregnancy should not alter the standard management of an acute asthma attack.
3. Patients presenting to the Emergency Room in a Maternity Hospital with an acute LIFE
THREATENING ASTHMA attack should be given salbutamol via oxygen driven nebuliser and
immediately referred to a General Hospital or service with respiratory medicine expertise
and ICU facilities.
| A National Clinical Guideline | Management of an Acute Asthma Attack in Adults
(aged 16 years and older) 45

4. Consider intensive care medicine consult with senior anaesthetist and need for possible
intubation and ventilation for those patients with deteriorating condition.
5. Continuous fetal monitoring is recommended in cases of severe or life threatening acute
asthma presentation.
6. If a patient with LIFE THREATENING ASTHMA requires delivery this should be performed by
an obstetric team in a general hospital with ICU and respiratory physician back up.
7. A patient with a SEVERE/MODERATE asthma attack not improved by initial nebulizer and
oxygen treatment should be immediately transferred to a general hospital with ICU facilities.
8. CXR*/ECG/ABG should be performed in patients presenting with acute asthma attack
(except where the presentation is MILD).
* use abdominal shielding and defer unless deemed urgent in the first trimester.
9. Respiratory physician input should be sought regarding the ongoing management of
pregnant patients admitted to a maternity hospital with an asthma attack. A consultation
with a respiratory physician to advise on further treatment options and follow up on
discharge.
10. Patients presenting with an acute asthma attack in pregnancy should be followed up on
discharge with the respiratory service to reduce incidence of further attack in pregnancy.
11. Consideration for other pathologies should be given for women presenting in pregnancy
with respiratory symptoms similar to acute asthma including those who do not have a
history of asthma. Pulmonary embolism, pulmonary oedema secondary to pre-eclampsia,
puerperal cardiomyopathy, pneumonia, ischemic or valvular heart disease may also
present with shortness of breath, hypoxia or respiratory wheeze.

Responsibility recommendation 23: Clinicians and nursing staff


Recommendation 23: Give drug therapy for acute asthma as for the non-pregnant patient including
systemic steroids and magnesium sulphate
Grade: C

Responsibility recommendation 24: Clinicians and nursing staff


Recommendation 24: Deliver high flow oxygen immediately to maintain oxygen saturation between 94-
98%
Grade: D

2.2.4 Discharge and follow-up


What discharge and follow-up planning is required for patients with an acute asthma attack?
People with a life threatening/severe asthma attack should be admitted for at least 24 hours
and should be reviewed by senior physician/ respiratory consultant before discharge. Patients
whose peak flow is greater than 75% best or predicted one hour after initial treatment may
be discharged from ED unless they meet any of the following criteria when admission may be
appropriate:
• Still have significant symptoms
• Previous near-fatal or brittle asthma
• Had an attack despite adequate dose steroid tablets pre-presentation
• Presentation at night
• Pregnancy.
| Management of an Acute Asthma Attack in Adults | A National Clinical Guideline
46 (aged 16 years and older)

What role can patient education play in asthma management following an acute asthma
attack?
“Following discharge from hospital or emergency departments, a proportion of patients re-
attend. International data has shown that more than 15% re-attended within two weeks. Some
repeat attenders need emergency care, but many delay seeking help, and are under-treated
and/or under-monitored”.
Level of evidence 2+ (BTS/SIGN 2014)

“Prior to discharge, trained staff should give asthma education. This should include education
on inhaler technique and PEF performance and record keeping. A written PEF and symptom-
based action plan should be provided allowing the patient to adjust their therapy within agreed
parameters. These measures have been shown to reduce morbidity after the attack and reduce
relapse rates”.
Level of evidence 1++ (BTS/SIGN 2014)

“There is some experience of a discrete population of patients who use emergency departments
rather than primary care services for their asthma care. Education has been shown to reduce
subsequent hospital admission and improve scheduled appointments and self management
techniques but does not improve re-attendance at emergency departments”. (BTS/SIGN 2014)

“For the above groups there is a role for a trained asthma liaison nurse based in, or associated
with, the emergency department.”
Level of evidence 1++ (BTS/SIGN 2014)

All patients following an asthma attack should be educated in the management of their
condition which can be provided by healthcare professionals trained in asthma management.
This should include;
• Awareness of triggers and symptoms of onset of attack
• Medications compliance
• Inhaler technique (see www.hse.ie, www.irishthoracicsociety.com, www.asthmasociety.ie
for copies of checklists)
• Peak flow technique and diary recording
• Asthma Management Plan (see Appendix 2.5)

People requiring further supports prior to discharge should be referred to appropriate services.
Such patients include:
• Those who live alone or are socially isolated
• Those who have behavioral or psychological problems
• Substance misuse
• Those who have a physical disability or learning difficulties
• Those who are currently on sedatives or psychiatric medication

“Prior to discharge, trained staff should give asthma education. This should include education
on inhaler technique and PEF performance and record keeping. A written PEF and symptom-
based action plan should be provided allowing the patient to adjust their therapy within agreed
parameters. These measures have been shown to reduce morbidity after the attack and reduce
relapse rates”.
Level of evidence 1++ (BTS/SIGN 2014)

“There is some experience of a discrete population of patients who use emergency departments
rather than primary care services for their asthma care. Education has been shown to reduce
subsequent hospital admission and improve scheduled appointments and self management
techniques but does not improve re-attendance at emergency departments.” (BTS/SIGN 2014)
| A National Clinical Guideline | Management of an Acute Asthma Attack in Adults
(aged 16 years and older) 47

“For the above groups there is a role for a trained asthma liaison nurse based in, or associated
with, the emergency department.”
Level of evidence 1++ (BTS/SIGN 2014)

What should the follow up process be after an acute asthma attack?


“A careful history should elicit the reasons for the attack and explore possible actions the
patient should take to prevent future emergency presentations. Medication should be altered
depending upon the assessment and the patient should be provided with an asthma action
plan aimed at preventing relapse, optimising treatment and preventing delay in seeking
assistance in the future.” (BTS/SIGN 2014).

It is recommended that follow up be arranged prior to discharge with the patient’s general
practitioner or asthma nurse / hospital specialist asthma/respiratory service as follows:
• The appropriate General Practice should be informed and receive appropriate discharge
summary by fax / email within 24 hours of the patient’s discharge
• Before discharge the patient should be instructed to arrange an appointment with their GP
or practice nurse within 2 working days of discharge.
• A requisition for a follow-up appointment with a hospital asthma / respiratory service should
be made within 4 weeks of the episode.

“Assisting patients in making appointments while being treated for acute asthma in emergency
departments may improve subsequent attendance at primary care centres.”
Level of evidence 1+ (BTS/SIGN 2014)

Discharge bundle following an acute adult asthma attack


A sample discharge bundle can be found in Appendix 2.2.

Discharge letter/fax/email template following an acute adult asthma attack


A sample discharge letter/fax/email template can be found in Appendix 2.3. A copy of the
discharge letter should be provided to each of the following:
• the patient with asthma attack or their carer
• the patient’s named GP /practice nurse
• care home/community nurse (where appropriate)
• Discharge from hospital or ED should be a planned, supervised event which includes
self-management planning. It may safely take place as soon as clinical improvement is
apparent.
• Prior to discharge, in patients should receive written personalised action plans, given by
clinicians with expertise in asthma management.
• Prescribe inhalers only after the patient has received training in the use of the device and
has demonstrated satisfactory technique.
• All people attending hospital with acute attack of asthma should be reviewed by a clinician
with particular expertise in asthma management, preferably within 30 days.

Responsibility recommendation 25: All healthcare staff


Recommendation 25:
Discharge from hospital or ED should be a planned, supervised event which includes self-management
planning. It may safely take place as soon as clinical improvement is apparent and sustained
Grade: A
| Management of an Acute Asthma Attack in Adults | A National Clinical Guideline
48 (aged 16 years and older)

Responsibility recommendation 26: Clinicians and nursing staff


Recommendation 26:
Prior to discharge, in patients should receive written personalised action plans, given by clinicians with
expertise in asthma management.
Grade: A

Responsibility recommendation 27: Clinicians


Recommendation 27:
Prescribe inhalers only after the patient has received training in the use of the device and has
demonstrated satisfactory technique.
Grade: B

Responsibility recommendation 28: Clinicians


Recommendation 28:
All people attending hospital with acute exacerbations of asthma should be reviewed by a clinician
with particular expertise in asthma management, preferably within 30 days.
Grade: A
| A National Clinical Guideline | Management of an Acute Asthma Attack in Adults
(aged 16 years and older) 49

3 Appendices and references

Appendix 1: Guideline Development Group

Appendix 1.1 Terms of reference


To develop a national evidence-based clinical guideline for the management of acute adult
asthma attacks

Appendix 1.2. Membership of Guideline Development Group

National Clinical Programme Prof. Pat Manning, Respiratory Consultant, Midland


Lead Regional Hospital , Mullingar
ICGP Lead Dr Dermot Nolan, General Practitioner, Tramore Medical
Clinic, Waterford
Public Health Specialist Dr Ina Kelly, Consultant in Public Health, HSE, Tullamore
Patient Organisation Dr Jean Holohan, CEO Asthma Society of Ireland
(2006-2012)

Sharon Cosgrove, CEO Asthma Society of Ireland (2012-


date)
Clinical Nurse Specialist (Adult) Ann Tooher, Midland Regional Hospital, Mullingar
Clinical Nurse Specialist Niamh O’Regan, Mullingar Midland Hospital, Mullingar
(Children) (2010-2013)
Advanced Nurse Practitioner Mary McDonald, Tallaght Hospital, Dublin
Asthma (Children)
Professional Development Rhonda Forsythe, Practice Nurse Development Co-
Coordinator for Practice ordinator, HSE
Nursing Service Planner Marian Wyer, HSE, Tullamore
Respiratory Scientists Maria McNeill, Respiratory Scientist, Midland Regional
Hospital, Mullingar (2010-2012)

Tom Kelly, Respiratory Scientist, Mater Misericordiae


Hospital, Chair of IARS (2012-2014)

Geraldine Nolan, Respiratory Scientist, St Vincent’s University


Hospital, Dublin 4
Therapy Professions Joanne Dowds, Clinical Specialist Physiotherapist, St.James
Representative Hospital, Dublin 8
| Management of an Acute Asthma Attack in Adults | A National Clinical Guideline
50 (aged 16 years and older)

Programme Managers Vanessa Colgan, Clinical Strategy and Programmes


Directorate , HSE (2010-2013)

Noreen Curtin, Clinical Strategy and Programmes


Directorate, HSE (2013-2014)

Regina Black, Clinical Strategy and Programmes


Directorate, HSE (2014-2015)

Linda Kearns, Clinical Stategy and Programmes Directorate


Health Intelligence Unit Davida DeLaHarpe, Head Health Intelligence Unit, HSE
QCCD

Anne O’Farrell, Health Intelligence Unit, HSE QCCD


Irish Pharmacy Union Pamela Logan, Director Pharmacy Service, IPU
Pharmacist Kathleen Niamh Buckley, Trinity College Dublin and St
James’s Hospital, Dublin 8
Contributors and Consultation Participants
Regional Lead DNE Dr John Faul, Respiratory Consultant, Connolly Hospital,
Dublin
Regional Lead DML Prof Stephen Lane, Respiratory Consultant, Tallaght Hospital,
Dublin 24
Regional Lead South Dr Terry O’Connor, Respiratory Consultant, Mercy University
Hospital, Cork
Regional Lead West Dr Robert Rutherford, Respiratory Consultant, Merlin Park
Hospital, Galway (up to March 2012)

Prof. Anthony O’Regan, University Hospital Galway (March


2012 to date)
RCPI / ITS Clinical Advisory Regional Leads and the following RCPI/ITS Nominees
Group
Dr Aidan O’Brien, Respiratory Consultant, Mid Western
Regional Hospital Limerick

Dr Barry Linnane, Respiratory Consultant, Mid Western


Regional Hospital Limerick

Dr Basil Elnazir, Paediatric Respiratory Consultant, Tallaght


Hospital, Dublin 24

Dr Des Murphy, Respiratory Consultant, Cork University


Hospital
| A National Clinical Guideline | Management of an Acute Asthma Attack in Adults
(aged 16 years and older) 51

Guideline National Consultative Groups


National Emergency Medicine Dr Una Geary, ED Programme Lead, Consultant in
Programme Emergency Medicine, St. James Hospital, Dublin 8

Prof. Ronan O'Sullivan, Head of Paediatrics, School


of Medicine & Medical Science, UCD , Consultant in
Paediatric Emergency Medicine Our Lady's Children's
Hospital Crumlin, Dublin 8
National Acute Medicine Dr Garry Courtney, Acute Medicine Programme Lead,
Programme Clinical Director, St Luke’s Hospital Kilkenny

Prof Shane O’Neill, Acute Medicine Programme Lead,


Respiratory Consultant, Beaumont Hospital, Dublin 7
National Paediatric Programme Prof Alf Nicholson, Consultant Paediatrician, Children’s
University Hospital, Temple Street, Dublin
Pre-Hospital Emergency Care Dr Geoff King, Director, Pre-Hospital Emergency Care
Council Council (R.I.P)

Brian Power, Pre-Hospital Emergency Care Council


National Critical Care Dr Michael Power, National Clinical Lead
Programme
Irish College of General Quality in Clinical Practice Committee
Practicitioners (ICGP)
External Reviewer Prof Mark Fitzgerald, Professor of Medicine, Head, UBC and
International Asthma Advisor VGH Divisions of Respiratory Medicine, Director, Centre for
Chairman of Scientific Lung Health, The Lung Centre, Vancouver, Canada
Committee GINA
DCU School of Nursing and Dr Veronica Lambert, Deputy Head of School and Senior
Human Sciences Faculty of Lecturer in Nursing
Science and Health Professor Anne Matthews, Head of School and Associate
Professor in Health Sciences
Ms Jessica Collins, Lecturer in General Nursing
Ms Catherine Walshe, Research Assistant
| Management of an Acute Asthma Attack in Adults | A National Clinical Guideline
52 (aged 16 years and older)

Appendix 1.3. Consultation process


As part of the guideline development process the draft guideline was circulated to key
stakeholders for feedback. A summary of the feedback provided during the consultation
process in presented below:

Feedback Feedback Provided: Incorporation of Feedback:


Submitted by:
Clinical Care • Dr Carmen Regan contributed text for the • Contribution gratefully
Programme, management of acute asthma exacerbation in received and incorporated
Obstetrics and pregnancy section into the guideline
Gynaecology

Irish Thoracic • ITS supportive of the development of acute asthma guidelines


Society
Irish College • ICGP supportive of the development of acute asthma guidelines
of General
Practitioners (ICGP)
Pre-Hospital • Inclusion of ‘PHECC’ in Glossary • PHECC inserted in glossary
Emergency Care
Council (PHECC)
• Inclusion of Pre-Hospital emergency care • Table 4 updated
practitioners and PHECC in table 4 Roles and
responsibilities of stakeholders

Emergency • Asked to consider dosage of IM • 160mg recommended by


Medicine methylprednisolone BTS/SIGN guideline and
Programme agreed by NCPA CAG
members
• Advised that early clinical input by Critical Care • Feedback incorporated
teams, particularly consultation with Critical into the guideline
Care Programme before the patient needs
intubation, be included
• Suggested that people requiring further • Feedback incorporated
supports prior to discharge should also include into the guideline
those with a history of substance misuse
• Suggested that follow up after discharge takes • Feedback incorporated
place ‘within 4 weeks of the episode’ into the guideline
• Suggested inclusion of ‘treatment protocols will • Feedback incorporated
be carried out by Emergency/Acute Medicine/ into the guideline
Respiratory teams.’
| A National Clinical Guideline | Management of an Acute Asthma Attack in Adults
(aged 16 years and older) 53

Appendix 2: Summary of tools to assist in implementation of


National Clinical Guideline
The following tools are presented in Appendix 2:

2.1. Emergency Treatment Protocols for Management of Acute Adult Asthma


Emergency treatment protocols are standardised flow of treatment to be applied to the
acute asthmatic
• Management of Acute Adult Asthma in ED, AMU & In hospital
• PHECC clinical practice guidelines (CPGs)

2.2. Emergency Treatment Care Bundles for Management of Acute Adult Asthma
• Management of asthma attack in general practice care bundle
• Life Threatening Asthma Attack Care bundle
• Severe/Moderate Asthma Attack Care Bundle
• Asthma Patient Discharge Care Bundle

2.3. Discharge Letter, Fax, Email Template for Management of Acute Adult Asthma

2.4. Audit Form for Emergency Asthma Care

2.5. Asthma Management Plans

2.6. Peak flow Measurements

2.7. Medications in Acute Asthma


| Management of an Acute Asthma Attack in Adults | A National Clinical Guideline
54 (aged 16 years and older)

Appendix 2.1 Emergency treatment protocols for management of acute adult asthma

Management of acute
Management adult
of Acute asthma
Adult Asthmain ED,
in ED, AMU
AMU and & In Hospital
in Hospital

Initial Assessment
Look for LIFE THREATENING FEATURES - take history, physical examination (auscultation, use of accessory
muscles, heart rate, respiratory rate, PEF, or FEV1, oxygen saturation, arterial blood gas if patient in extremis)

PEF < 33% best or predicted PEF 33–50% best or predicted PEF 50-75% best or PEF >75% best or
SpO2 <92% OR any one of the SpO2 >92% predicted predicted
SpO2 >92% SpO2 >92%
Life Threatening Asthma Features: Severe Moderate Mild
 Silent chest, cyanosis, poor  PEF <50% (severe) - Loud wheeze - Can lie down
respiratory effort  Respiration >25 breaths/min - Prefer to sit - Talks in sentences
 Bradycardia, arrhythmia,  Pulse > 110 beats/min - Talks in phrases - Mild-Mod wheeze
 Check BP for hypotension  Cannot complete sentence in one - PR<110 Beats/ min - PR<100 Beats/ min
 Exhaustion, confusion, coma breath - RR<25 Breaths/ min - RR<25 Breaths/ min
 BP Normal - BP Normal - BP Normal

Obtain Senior/ICU/ Specialist help Give salbutamol


Give salbutamol 5 mg and ipratropium up to 12 puffs via Give usual
now if any life threatening asthma
0.5mg by oxygen-driven nebuliser spacer or oxygen bronchodilator
features are present
driven nebuliser
IMMEDIATE MANAGEMENT
 High concentration oxygen (>60% if
possible – goal to maintain sats at
94%) Life
 Give salbutamol 5 mg plus Clinically
threatening No life threatening asthma features
ipratropium 0.5 mg via oxygen- stable
10 -15 driven nebuliser
asthma AND
AND
features OR PEF 50-75%
mins  AND prednisolone 40-50mg orally PEF <50%
PEF >75%
or IV hydrocortisone 100 mg or Repeat salbutamol via inhaler/
125mg of methyprednisolone nebulizer 5mg at 15-30 min intervals
Measure arterial blood gases
Markers of severity: Give prednisolone 40-50mg orally
 Normal or raised PaCO2
(Pa CO2>4.6kPa)
 Severe hypoxia
(Pa O2<8 kPa)
 Low pH (or high H+)

 Chest X-ray Signs of severe No signs of severe


Patient recovering
 12-Lead ECG Asthma Asthma
AND PEF >75%
 Give/repeat salbutamol 5 mg with OR PEF <50% AND PEF 50-75%
ipratropium 0.5 mg by oxygen-
driven nebuliser after 15 minutes
 Consider continuous salbutamol OBSERVE
nebuliser 5-10 mg/hr. Monitor SpO2,
 Consider IV magnesium sulphate Heart rate and
2g over 20 minutes Respiratory rate
 Correct fluid/electrolytes, especially
2 K+ disturbances
hours

ADMIT for minimum of 24 hours Signs of severe Patient Stable Start on inhaled
Patient should be accompanied by a asthma AND PEF >50% Steroids
nurse or doctor at all times OR PEF <50%

Peak expiratory flow in normal adults DISCHARGE PLAN


 In all patients who received nebulised ß2 agonists prior to
presentation, consider an extended observation period prior to
discharge
 If PEF<50% on presentation, prescribe prednisolone 40-50mg/
day for 5 days. Ensure all patients have a treatment supply
 In all patients ensure treatment supply of inhaled steroid and
ß2 agonist as a minimum and check inhaler technique
 PEF meter instruction and written asthma management plan
 Consider psycho-social factors before discharge
 GP follow up within 2 working days post presentation advised
for moderate / severe / life-threatening exacerbation (2 weeks
– mild)
 Fax Or email discharge letter to GP and copy to patient
 Refer to Asthma/ Respiratory Service for follow up within 4
weeks
 Complete Asthma Discharge Plan
 Consider delay in discharge to 8 am if after midnight
Based
Based on
on GINA
GINA and
and BTS
BTS Guideline
Guideline on
on the
the Management
Management of
of Asthma
Asthma 2008
2008
| A National Clinical Guideline | Management of an Acute Asthma Attack in Adults
(aged 16 years and older) 55

PHECC Clinical Practice Guideline

4/5/6.3.4
Version 2, 05/14 Asthma – Adult EMT P

Asthma/ AP
bronchospasm
Assess and maintain airway

Respiratory assessment

Salbutamol, 5 mg, NEB

Mild Asthma OR
Salbutamol If no improvement Salbutamol
(0.1 mg) metered aerosol aerosol, 0.1 mg may be repeated
up to 5 times as required

Resolved/
Yes
improved

No

ECG & SpO2 monitoring

Oxygen therapy

Request

ALS

Salbutamol, 5 mg, NEB


OR
Moderate Asthma Ipratropium bromide 0.5 mg
NEB & salbutamol 5 mg NEB
mixed

Resolved/
Yes
improved

No

Salbutamol, 5 mg, NEB

Resolved/
Yes
improved

No

Hydrocortisone, 100 mg slow IV


Severe Asthma (infusion in 100 mL NaCl)

Salbutamol, 5 mg, NEB

Resolved/
Yes
improved

No

Life-threatening Consider
Asthma Magnesium Sulphate 2 g IV
(infusion in 100 mL NaCl)

Salbutamol, 5 mg, NEB


Every 5 minutes prn

Reference: HSE National Asthma Programme 2012, Emergency Asthma Guidelines, British Thoracic Society, 2008, British Guidelines on the Management
of Asthma, a national clinical guideline
| Management of an Acute Asthma Attack in Adults | A National Clinical Guideline
56 (aged 16 years and older)

Appendix 2.2 Emergency treatment care bundles for management of acute adult asthma

Adult Asthma Acute Management in General Practice and Primary Care out of hours settings

Assess and Record: Peak expiratory flow; Symptoms and response to self treatment; Heart and respiratory
rates; Oxygen Saturation (by pulse oximetry, if available)

Caution: Patients with severe or life threatening attacks may not be distressed and may not have all the
abnormalities listed below. The presence of any should alert the doctor

Regard each emergency asthma consultation as for acute life threatening/severe asthma until it is
shown otherwise

Date (of review): _________________ Time: ___________________ Time Processed


Nurse/Physician
Initials/Comments

r Give Oxygen via face mask if available, 40 – 60%

If Moderate asthma attack (PEF 50-75%):


r Give β2 agonist via spacer up to 12 puffs (given one at a time and inhaled
separately) at intervals of 15 - 30 minutes

If Severe/ Life threatening (< 50%):


r Administer salbutamol 5mg or terbutaline 10mg via oxygen driven nebuliser

If PEF 50-75% predicated/best:


r Administer prednisolone 40 - 50mg orally or
r IV hydrocortisone 100mg

All patients who received nebulised β2 agonist, require extended observation period

r Assess response to treatment in 15 minutes post administration of β2agonist,


continually observing symptoms

r If NO response arrange immediate admission to Hospital ED /AMU


Dial 112 0r 999
r Administer High Dose β2 agonist and ipratropium 0.5mg via nebuliser
r Stay with patient until ambulance arrives
r Send documentation assessment and referral to hospital
r Ensure patient is given high dose β2 agonist via oxygen driven nebuliser in
ambulance

r If GOOD response, the patient’s symptoms improve


r Continue step up of usual treatment and continue course of oral predsnisolone
r Ensure the patient has a prescription for β2 agonist and inhaled steroid (if not
already on inhaled steroids) prior to discharge
r Commence PEF diary and encourage charting symptoms in the asthma
management plan
r Check technique of use inhaler and peak flow meter
r Demonstrate inhaler technique and peak flow use to new patients and carer as
appropriate.
r Arrange GP follow up within 2 working days
| A National Clinical Guideline | Management of an Acute Asthma Attack in Adults
(aged 16 years and older) 57

Attack of Life Threatening Asthma (Adult) in ED/ AMU Management Bundle

Life Threatening Asthma


PEF<33% best or predicted OR any one of the life threatening asthma features:
Sp02 < 92%, silent chest, cyanosis, poor respiratory effort, bradycardia, arrhythmia, hypotension,
exhaustion, confusion, coma. Patient should be monitored continuously.

Date:_________________ Time:___________________________ Time Processed


Nurse/Physician
Initials/Comments

Give high concentration Oxygen (60%) to maintain Sp02 greater than 94%

Administer Salbutamol 5mg + Ipratropium 0.5mg by oxygen driven (6-8L/min)


nebulizer (within 5 mins of arrival) and repeat every 15mins until improvement from
above.

Prednisolone 40-50 mg PO or IV hydrocortisone 100mg or 125mg methylprednisolone

Cardiac monitor, pulse oximetry and Insert IV line

ABG – Measure arterial blood gases


Markers of severity:
r Normal or raised PaCO2 (Pa CO2>4.6kPa)
r Severe hypoxia (Pa O2< 8 kPa)
r Low pH (or high H+)

Assess need for intubation and ventilation, if yes contact anaesthetist/Critical care
team
r

If poor or no response (following consultation with senior physician)


r Magnesium sulphate 2g IV in 50ml Normal Saline over 20 minutes

Chest X-Ray

12-lead ECG

FBC, electrolytes, BUN, SCr, blood glucose

Decision to Admit to ICU/HDU

Physician Signature Printed Name

_________________________ ___________________________

Table for Approved Medications Administration Affix Patient Label Here

Medication Nurse Nurse Prescriber Physician


Oxygen √ √ √
Salbutamol √ √ √
Ipratropium √ √
Prednisolone √ √
/Methylprednisolone
| Management of an Acute Asthma Attack in Adults | A National Clinical Guideline
58 (aged 16 years and older)

Asthma Discharge Checklist from ED and AMU

Review each of the steps and incorporate into your discharge planning process for an Asthma Patient

Date (of discharge):________________________Time_______________________ Time Processed


Nurse/Physician
Initials/Comments

r Consider psycho-social factors in discharge and refer to MDT or agency if required

r Consider delay in discharge to 8am if after midnight

r If patient received nebulised β2 agonists prior to presentation to ED/AMU consider


an extended observation period (more than 4 hours) prior to discharge

r If PEF < 50% on presentation, prescribe oral prednisolone 40-50 mg/day for 5 days

r Ensure prescription for oral (if required) and inhaled steroid β2 agonist is supplied to
patient on discharge (GMS patient go to GP for medical card prescription)

r Check inhaler technique

r Implement written asthma management plan and diary

r Purchase own PEF meter from Asthma Society of Ireland (ASI) or pharmacy

r Advise patient to arrange GP follow up for within 2 working days of presentation for
moderate/ severe/ life-threatening asthma (within 2 weeks – mild)

r Fax or email discharge letter to GP


r Copy to Asthma nurse/respiratory service

Physician Signature Printed Name

_________________________ ___________________________

Affix patient Label here


| A National Clinical Guideline | Management of an Acute Asthma Attack in Adults
(aged 16 years and older) 59

Appendix 2.3. Discharge letter, fax, email template for management of acute adult asthma

Discharge Letter following acute asthma attack to Emergency Department / Hospital

Hospital Name

Patient Name: __________________________________________ DOB: ________________________

Address _____________________________________________________________________________________________

Date /time ___________________________________

Dear (GP’s Name) _____________________________________________________________

Age: Height Predicted Peak Flow:

Initial assessment On discharge


PEF
SpO2
Pulse
Respiratory rate

We have discussed
r Inhaler use / technique with (type) ……………...........................................…………………………………….
r Medicines including side effects ………………….............................................………………………………….
r Trigger avoidance ……………………………………..................................................………………………………..
r Smoking cessation ……………………………...................................................………………………………………
r How to recognise worsening asthma and what to do in asthma attack: ....................................…
Was given a leaflet detailing a simple management plan (copy enclosed) …...............................……….
……………………………………………………………..........................................................………………………………

Other important issues discussed:


1 ..……………………………………………………………………..........................…………………….......................…
2 ……………………..................................................……………………………………………………………………….
3 …………….................................................………………………………………………………………………………..
………………………………………………………........................................................................................................…
……………………………………………………………………………………………………………………………………

They have been given written information about asthma management

They have been referred to:


Asthma Nurse Specialist …………………………………………………………..
Respiratory Consultant …………………………………………………………….
Other ……………………………………………………………………………….

For follow up appointments.


They have been discharged on the following medications:

Contact Details: Emergency Department


Signature: Hospital
Name:
Title:
Bleep:
| Management of an Acute Asthma Attack in Adults | A National Clinical Guideline
60 (aged 16 years and older)

Appendix 2.4. Audit form for emergency asthma care

Audit Form for Emergency Asthma Care

Patient Name: ……………………………………………………………..


DOB: …………………………………… Date/Time: ……………………………………

Yes No N/A

1. PEF on admission and after treatment (in anyone over 5 years) r r r

2. Pulse rate, respiratory rate and SpO2. Where SpO2< 92% check arterial r r r
blood gases and give oxygen as appropriate

3. Inhaler technique checked and recorded r r r

4. Relevant past medical history recorded (asthma and atopy in particular) r r r

5. Triggers identified and avoidance discussed r r r

6. Current medicines recorded, including dose, frequency (or their absence) r r r


recorded

7. Concordance issues addressed r r r

8. Psycho-social or other risk factors r r r

9. Stable on four hourly treatment or when PEF >75% of best or predicted r r r

10. Steroid tablets given as appropriate, as per GINA guidelines r r r

11. Provided written information and action plan r r r

12. Follow-up with GP within 2 working days of discharge advised for r r r


moderate/severe/life-threatening asthma (2 weeks – mild) and discharge
letter sent

Where you have ticked N/A (not applicable) please explain here e.g. No Peak flow as under 5
HOW TO USE YOUR
PEAK FLOW METER Asthma
1. Measure your peak flow morning and evening
before taking your inhalers. Management Plan
. 2. Sit up straight. Peak Flow Diary
3. Push the pointer on the peak flow meter to
base/zero. THESE INSTRUCTIONS ARE GUIDELINES,
REGARDLESS OF THE ADVICE IN THE PLAN, IF
4. Take a deep breath in. YOU ARE UNHAPPY ABOUT YOUR CONDITION
SEEK MEDICAL HELP.
5. Grip the mouthpiece with your teeth and seal
| A National Clinical Guideline

with your lips. Take care not to cover or block the


PM pointer with your finger. Name:
6. Blow as hard and fast as you can. (Short, sharp
blast) Address:

7. Do this 3 times and record the highest reading.


Phone:
If you are unsure of how to use your peak flow meter go
Appendix 2.5. Asthma Management Plan

to the Asthma Society of Ireland website


www.asthmasociety.ie for a video demonstration.
Emergency Contact:

WHAT TO DO IN Relationship:

Date and Signature of Health Care Professional


AN ASTHMA ATTACK
Mobile Phone:
“THE FIVE MINUTE RULE”
Home Phone:
1. Ensure the reliever is taken immediately. This is
usually blue and opens up narrowed airways.

nnn nnn nnn nnn nnn


nnn nnn nnn nnn nnn
nnn nnn nnn nnn nnn
nnn nnn nnn nnn nnn
nnn nnn nnn nnn nnn
nnn nnn nnn nnn nnn
nnn nnn nnn nnn nnn
nnn nnn nnn nnn nnn
nnn nnn nnn nnn nnn
nnn nnn nnn nnn nnn
GP:
2. Sit down and loosen tight clothing.
GP Contact Number:
3. Attacks may be frightening and it is important to
stay calm.
In Emergency Go To:
(aged 16 years and older)

4. If no immediate improvement during an attack,


continue to take the reliever every minute for five Phone:
minutes or until symptoms improve: two puffs of
MDI/evohaler or one puff of turbohaler.

5. If your symptoms do not improve in five minutes,


or if you are in doubt, call 999 or 112 or a Tel: (01) 817 8886
doctor urgently. Continue to take reliever until Fax: (01) 817 8878
help arrives or symptoms improve. Use a spacer Asthma Advice Line
device if possible for maximum benefit. 1850 44 54 64

Education:
Inhaler Technique
Relievers & Controllers
Peak Flow Measuring / Recording
Asthma Self Management Plan
Allergic Triggers
Nasal Congestion / Medication
Exercise
Emergency Home Steroids
Smoking Cessation
Flu Vaccine (administered by)

Email: office@asthmasociety.ie
www.asthmasociety.ie
| Management of an Acute Asthma Attack in Adults
61
Project1_Layout 1 09/05/2011 06:46 Page 7

62
ASTHMA MANAGEMENT PLAN Date you started this Diary 8/11 9/11 10/11 12/11 Date Date
1. Have you had any asthma symptoms during the day (coughing, wheeze, tight chest or feeling breathless). 3
2. Has your asthma interfered with your usual activities (e.g. housework, climbing stairs, work or school, exercise). 3 3

E
3. Have you had difficulty sleeping because of your asthma symptoms (including coughing) 3
4. Have you needed to use your reliever inhaler more than twice a week

L
5. Have you had nasal symptoms (eg nasal congestion, sneezing, post nasal drip etc.)
Write down the total number of times
GREEN ZONE: ASTHMA UNDER CONTROL you took your treatment each day. Write down the total number of times you took your treatment each day. Write down the total number
Your Regular Treatment. Each day take:

P
Peak Flow 1. Reliever _______________________________________________________________________________________________________
n Daytime symptoms less than twice/week
between
n No limitation of exercise 80-100% 2. Controller _____________________________________________________________________________________________________ 3

M
n No waking at night due to symptoms of 3. ______________________________________________________________________________________________________________
3
Personal
n Reliever medication used less than twice per week

A
Best 4. ______________________________________________________________________________________________________________
n Peak flow between _________ and ___________ AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM
Before Exercise take _______________________________________________________________________________________________ 700 700 700

X
BLUE ZONE: ASTHMA GETTING WORSE
(aged 16 years and older)

If you answered ‘yes’ to 3 or more of these questions, your asthma is uncontrolled


and you may need to step up your treatment.

E
n Daytime symptoms more than twice/week? Peak Flow
Step up your treatment as follows:
n Getting chesty cough? between
1. Increase your reliever to ________________________________________________________________________________________ 600 600 600
n Waking at night with cough or wheeze? 60-80%
2. Take __________________________________________________________________________________________________________
n New or increased daytime cough or wheeze? of
______________________________________________________________________________________________________________
n Symptoms after activity or exercise? Personal
______________________________________________________________________________________________________________
n Using reliever meds more than twice per week? Best
The need for repeated doses over more than 1 or 2 days signals the need for a review by your doctor.
n Peak flow between _________ and ___________ Use a spacer device if possible for maximum benefit.

E
500 500 500

ORANGE ZONE: ASTHMA BECOMING SEVERE

n
n
Symptoms becoming more severe
Becoming breathless at rest
Peak Flow
between
Call your doctor/clinic: Phone No. _________________________ and get immediate advice.
Take the following medication.
1. Increase your reliever use to ____________________________________________________________________________________
P L 7
7
7

7
7

7
2. Additional Instructions _________________________________________________________________________________________ 7 7
n Chest tightness 40-60% 400 400 400
______________________________________________________________________________________________________________
| Management of an Acute Asthma Attack in Adults

n Reliever medication has poor or of


______________________________________________________________________________________________________________
M
short lived effect Personal
Best 3. Take _____ mg of ________________________________ (oral steroid) if prescribed.
n Peak flow between _________ and ___________
Out of hours contact _____________________________________________________________________________________________
A
Use a spacer device if possible for maximum benefit.
300 300 300

RED ZONE: EMERGENCY Get medical help immediately.


Go to_____________________________________________________________________________ Phone: ______________________
n Shortness of breath Peak Flow
EX

is less than Out of Hours: ______________________________


n Can only speak in short sentences
n Trouble walking 40% Take 2 to 4 puffs of your reliever inhaler 200 200 200
n Lips are blue of 180 180 180
Take _____ mg of ________________________________ (oral steroid) if prescribed.
n Short lived response to reliever. Personal 160 160 160

n Peak flow is less than ____________ Best 140 140 140


Continue to take 2 puffs of reliever every minute until symptoms improve or help arrives.
Use a spacer device if possible for maximum benefit. 120 120 120

100 100 100


| A National Clinical Guideline
Appendix 2.6. Peak Flow Measurements

ADULT MALE NORMAL VALUES Peak Expiratory Flow Rate – Normal Values
Peak Expiratory Flow Rate
For use with EU/EN13826 scale PEF meters only
Height 680
AGE in yrs
1.6m 5’3” 1.67m 5’6” 1.75m 5’9” 1.83m 6’ 1.90m 6’3”
660
15 485 498 511 524 535
20 540 555 571 586 398 640
25 575 591 608 624 637 620
30 594 611 628 645 659
600
35 601 618 636 653 666
40 599 615 633 650 664
| A National Clinical Guideline

580
45 590 606 623 640 653 560
50 575 591 608 624 637
55 557 572 588 603 616 540

60 536 550 566 581 593 520


65 513 527 542 556 567
500
70 490 503 517 530 541
75 466 478 491 503 514 480 Height
80 552 453 465 477 487 Men

PEF (l/min) EU Scale


460
190 cm (75 in)
85 418 429 440 451 460
440
183 cm (72 in)
175 cm (69 in)
ADULT FEMALE NORMAL VALUES 420 167 cm (66 in)
Peak Expiratory Flow Rate 160 cm (63 in)
400
For use with EU/EN13826 scale PEF meters only
Height 380
AGE in yrs
1.52m 5’ 1.6m 5’3” 1.67m 5’6” 1.75m 5’9” 1.83m 6’
360
15 385 394 402 411 418 Height
340 Women
20 409 419 428 437 445 183 cm (72 in)
25 422 433 441 451 459 320 175 cm (69 in)
30 427 437 446 456 465 167 cm (66 in)
(aged 16 years and older)

300 160 cm (63 in)


35 425 436 445 454 463
15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 152 cm (60 in)
40 420 431 439 449 457
Age (years)
45 412 422 431 440 448
50 401 411 419 428 436 Adapted by Clement Clarke for use with EN13826 / EU scale peak flow meters
55 389 399 407 415 423
from Nunn AJ Gregg I, Br Med J 1989:298;1068-70
60 376 385 393 401 408
65 362 371 378 386 393
70 348 356 363 371 378
75 334 342 348 355 362
80 320 327 334 340 346
| Management of an Acute Asthma Attack in Adults

85 306 313 319 325 331


63
Appendix 2.7. Medications in acute asthma
64

Medicine Class/Generic Adult Dose Comments


Name
Oxygen High Flow Adults with severe asthma are hypoxaemic and should be given high
flow oxygen to maintain oxygen saturation at 92% or above
β2 agonist bronchodilators/ Ideally salbutamol 5mg or terbutaline 10mg These act quickly to relieve bronchospasm and have few side effects.
salbutamol, terbutaline via oxygen driven nebuliser or up to 12 puffs They should be administered as early as possible in an asthma attack.
via spacer pMDI + spacer is preferable method of delivery.
(aged 16 years and older)

Repeat doses should be given at 15-30 12 PUFFS VIA SPACER IS JUST AS EFFECTIVE AS NEBULISER UNLESS FEATURES
minute intervals or continuous nebulisation OF LIFE-THREATENING ASTHMA ATTACK
of salbutamol at 5-10mg/hour if inadequate
response to initial treatment
Bronchodilators/ 0.5mg 4-6 hourly mixed with nebulised β2
Ipratropium agonist in severe or life threatening asthma
or those with a poor initial response to β2
agonist therapy
Steroids/Prednisolone 40-50mg daily for 3 to 7 days or until Steroid tablets reduce mortality, relapses and hospital admissions. The
| Management of an Acute Asthma Attack in Adults

recovery earlier they are given in an attack the better the outcome.
Following recovery steroid tablets can be dropped abruptly and do not
need tapering provided that the patient is receiving inhaled steroids
(apart from those patients on maintenance steroid tablets or where
steroid tablets are needed for more than three weeks).
Steroids/Hydrocortisone IV (100mg, 6 hourly) ONLY USE IV IF COMATOSE OR VOMITING AS ORAL PREDNISOLONE IS JUST
AS EFFECTIVE
IV Magnesium Sulphate 1.2 – 2g IV infusion over 20 minutes but Consider giving single IV dose for patients with severe asthma who have
should only be used following consultation not had a good initial response to inhaled bronchodilator therapy or for
with senior medical staff life threatening or near fatal asthma attacks
IV Aminophylline Use only after consultation with senior
medical staff
Antibiotics Routine prescription of antibiotics is not indicated for asthma. Infection
often triggers an episode but is more likely to be viral rather than
bacterial in type
| A National Clinical Guideline
Appendix 3: Search Sources and Outputs
Appendix 3.1 Guideline clearing houses and organisations which develop guidelines and/or support evidence based practice; search
sources and outputs

Databases/ Search Terms Date searched Hits Screen for eligibility Screen for eligibility
organisation EXCLUDE INCLUDE
US National Guideline Advanced Search 10/04/2015 50 N=48 N=2
Clearinghouse Keyword: acute asthma
www.guideline.gov management Reasons for exclusion One is BTS/SIGN – INCLUDE
| A National Clinical Guideline

Age of Target Population: Adult (19 Not specific to asthma


to 44 years), Middle Age (45 to 64 Not systematic evidence Second one is ICSI - EXCLUDE
years), Aged (65 to 79 years), Aged based clinical guideline
80 and over
Publication Year: 2011, 2012, 2013,
2014, 2015
Guidelines Search Guidelines 10/04/2015
International Network
www.g-i-n.net Acute adult asthma management 0 N=0 N=0

Acute asthma management 2 N=1 N=1

Asthma management 19 N=14 N=5

Reasons for exclusion KSUMC EBCPG 2013 –


Not specific to asthma localised; adapted from BTS/
Child focused SIGN – EXCLUDE
Not systematic evidence
(aged 16 years and older)

based clinical guideline GINA – INCLUDE


Published before 2011
KSUMC EBCPG Child -
EXCLUDE

3 Duplicates
| Management of an Acute Asthma Attack in Adults
65
Databases/ Search Terms Date searched Hits Screen for eligibility Screen for eligibility 66
organisation EXCLUDE INCLUDE
Scottish Intercollegiate Adult acute asthma management 10/04/2015 68 N=67 N=1
Guidelines Network guidelines
(www.sign.ac.uk ) Reasons for exclusion BTS/SIGN
COPD/RTI http://www.sign.ac.uk/
Not systematic evidence guidelines/fulltext/101/index.
based clinical guideline html - Duplicate
National Institute for Search under GUIDANCE 10/04/2015 55 N=54 N=1
Health and Clinical Adult acute asthma management
Excellence UK (www. Reasons for exclusion Quality Standard on Asthma
(aged 16 years and older)

nice.org.uk ) Focus on inhalers only 2013 (? Standard and in


Child focus accordance with BTS/SIGN
COPD guidance)- EXCLUDE
Other conditions i.e. not
asthma specific
New Zealand Adult acute asthma management 10/04/2015 33 N=33 N=0
Guideline Group
(NZGG) (http://www. Reasons for exclusion
health.govt.nz/about- Not guideline
| Management of an Acute Asthma Attack in Adults

ministry/ministry-health- Not specific to asthma


websites/new-zealand- Published before 2011
guidelines-group)
Centre for Clinical Screened the lists of the current 10/04/2015 0 N=0 N=0
Effectiveness Australia evidence reviews and resources
(http://www. (workbooks and toolkits) and other
monashhealth.org/ resources (NHMRC – see below)
page/CCE)
National Health and Searched: Guidelines and 10/04/2015 1 N=1 N=0
Medical Research Publications
Council (NHMRC) Filter by subject: asthma Reasons for exclusion
(Australia) It was ‘asthma:
management, education
and research’ but it was
dated 1995 and rescinded in
2005
| A National Clinical Guideline
Databases/ Search Terms Date searched Hits Screen for eligibility Screen for eligibility
organisation EXCLUDE INCLUDE
Clinical Practice Search by Condition 10/04/2015 13 N=12 N=1
Guideline Portal (NICS) Asthma
(https://www. Reasons for exclusion Web link http://www.
clinicalguidelines.gov. Not guideline asthmahandbook.org.
au/) Child focused au/ which brings one to
COPD Australian Asthma Handbook
2014 (and also a quick
reference guide)- INCLUDE
| A National Clinical Guideline

TRIP Database Advanced Search 10/04/2015 200 N=196 N=4


(www.tripdatabase. All of these words: adult acute
com) – for findings asthma management (anywhere Reasons for exclusion Canadian Thoracic Society
high-quality clinical in the document) Not guideline 2012 – Lougheed et al paper
research evidence This exact phrase: guideline (in title Child focused - INCLUDE
only) Chronic asthma
Start year: 2011 Not asthma focused – CPD; BTS/SIGN - Duplicate
End year: 2015 bronchiolitis, RTI etc.
Duplicate - Same one as nat.
clearing house (diagnosis
and management of
asthma)

Duplicate - One other


one from nat. clearing
house – Michigan Quality
Improvement Consortium –
principles for diagnosis and
(aged 16 years and older)

management of asthma
Outputs Hits First screen - Excluded 426 First screen - include as
441 potentially eligible 15

Second screen
Exclude 11
Include 4 (BTS/SIGN;
GINA; CTS; AUSTRALIAN
HANDBOOK)
| Management of an Acute Asthma Attack in Adults
67
Appendix 3.2. International asthma, thoracic and lung associations.
68

Organisations Search Term Date Hits Screen for eligibility Screen for eligibility
of search EXCLUDE INCLUDE
Asthma Societies/
Associations
Asthma UK http://www. Guidelines 11/4/15 58 N=55 N=3
asthma.org.uk/Default.aspx
Reasons for exclusion: BTS/SIGN (2014 guidelines -
Emergency asthma care INCLUDE)
(aged 16 years and older)

booklet; helplines for asthma


parents, patients ARIA (out of date/ 2010 -
EXCLUDE)

NICE guidelines (Asthma


Guidelines in Development at
Present) - EXCLUDE
British Society for Allergy and Asthma Guidelines 11/4/15 61 N=61 N=0
Clinical Immunology (BSACI)
| Management of an Acute Asthma Attack in Adults

www.bsaci.org Reasons for exclusion:


No asthma guidelines after
2008;
Rhinitis management guidelines
only

British Lung Foundation (BLF) Adult acute asthma guidelines 11/4/15 32 N=31 N=1
www.blf.org.uk Reasons for exclusion: NICE
SIGN guideline from 2008 (Asthma Standard ONLY) -
Exclude
Asthma Society of Ireland “guidelines” 11/4/15 9 N= 9 N=0
(ASI) Reasons for exclusion:
www.asthma.ie Information for patients/
families;
Mentions GINA guidelines
| A National Clinical Guideline
Organisations Search Term Date Hits Screen for eligibility Screen for eligibility
of search EXCLUDE INCLUDE
American Academy “asthma guidelines” 11/4/15 38 N=38 N=0
of Allergy Asthma and Reasons for exclusion: Education needs and practice
Immunology (AAAI) NIH 2007 guidelines gaps recognised-
https://www.aaaai.org/ NHLBI guidelines (2007) Asthma Management: a topic
home.aspx identified at the AAAI members
meeting on the 8/10/2014
Asthma and Allergy Asthma Management 11/4/15 51 N=51 N=0
Foundation of America Reasons for exclusion:
| A National Clinical Guideline

(AAFA) No clinical guidelines


www.aafa.org Refers to NAEPP panel 3
guidelines (2007)
National Heart, Lung and “asthma management” 11/4/15 192 N=191 N=1
Blood Institute (NHLBI) Reasons for exclusion:
www.nhlbi.nih.gov Out of Date Clinical Guidelines NHLBAC Asthma Report (2014)
(2007) (Not to be included as NOT a
Guidelines for families Guideline) – Exclude
National Institute of Allergy “asthma guidelines” 11/4/15 4 N=3 N=1
and Infectious Diseases Reasons for exclusion:
(NIAID) Development of guidelines NHLBI/NAEPP guidelines for
www.niaid.nih.gov Guidelines for food allergy with asthma (2014)
asthma (Not to be included- NOT
Council minutes from meeting Guidelines: REPORT only) –
for asthma guidelines Exclude
Association of Asthma Asthma Management 11/4/15 15 N=15 N=0
Educators (AAE) Reasons for exclusion:
(aged 16 years and older)

www.asthmaeducators.org Site only for courses for


educating health professionals
asthma management
Centres for Disease Control No Search Window 11/4/15 1 N=0 N= 1
and Prevention (CDC) Click: Diseases and Conditions NHLBI Guidelines (2014)
www.cdc.gov Click: Asthma (NOT to be included-Report
Click: Health Care Professionals ONLY) - Exclude
| Management of an Acute Asthma Attack in Adults
69
Organisations Search Term Date Hits Screen for eligibility Screen for eligibility 70
of search EXCLUDE INCLUDE
National Asthma Education “asthma management” 11/4/15 192 N=191 N=1
and Prevention Program Reasons for exclusion: NHLBAC report (2014) - Exclude
(NAEPP) Self-management guidelines;
www.nhlbi.nih.gov/about/ guidelines for patients and
org/naepp families; fact book

Canadian Society of Asthma Guidelines 12/4/15 1 N=0 N=1


Respiratory Therapists (CSRT)
www.csrt.com Hyperlink to GINA website -
(aged 16 years and older)

Duplicate
Asthma Society of Canada “asthma management” 12/4/15 34 N=33 N=1
(ASC) Reasons for exclusion:
www.asthma.ca Asthma videos; asthma action GINA guidelines (2014) – there
plans; news releases; health is 2015 version available
index; asthma control guide;
COPD guidelines using CTS
guidelines
Allergy and Asthma Advanced Search: 12/4/15 2 N=2 Click: Information about
| Management of an Acute Asthma Attack in Adults

Information Association All Words: Reasons for exclusion: Asthma


(AAIA) Adult acute asthma guidelines Anaphylaxis Guidelines for Click: Asthma Consensus
www.aaia.ca Any of these Words: Schools; Guidelines in French Guidelines update 2003=
Adult acute asthma guidelines Refers to CTS guidelines for
None of These Words: Children Adult Group
Show: 25 result per page
Description Text: Normal
Word Stemming: Automatic
European Federation Adult asthma guidelines 11/4/15 8 N=8 N=0
of Asthma and Allergy Reasons for exclusion:
Associations (EFA) All newsletters
www.efanet.org ARIA mentioned in a newsletter

European Academy Asthma guidelines 11/4/15 20 N=20 N=0


of Allergy and Clinical Reasons for exclusion:
Immunology (EAACI) Paediatric asthma guidelines;
www.eaaci.org Position statements
| A National Clinical Guideline
Organisations Search Term Date Hits Screen for eligibility Screen for eligibility
of search EXCLUDE INCLUDE
European Lung Foundation Asthma management 11/4/15 17 N=15 N=2
(ELF) Reasons for exclusion:
www.europeanlung.org Occupational; risk factors Newsletters suggest treating
of asthma; air pollution and asthma based on ERS/ATS
asthma guidelines – Exclude
European Respiratory Society Asthma management 11/4/15 31 N=29 N=2
(ERS) Reasons for exclusion: • GINA (2014); - Duplicate
www.ersnet.org Journals; world asthma day; • Publication includes ERS/ATS
| A National Clinical Guideline

- Exclude
Asthma New Zealand Asthma Management 11/4/15 9 N=9 N=0
www.asthma-nz.org.nz Reasons for exclusion:
Adult asthma management
plan; COPD management;
Asthma Management Nursing
Course
The Asthma Foundation Adult acute asthma guidelines 11/4/15 1 N=1 Recommended:
www.asthmafoundation.org. Reasons for exclusion: • BTS/SIGN
nz “seeking support to update • GINA guidelines
guidelines” (until website has the updated
2002 guidelines only guidelines in place)
Asthma Australia Click: Health Professionals 11/4/15 1 N=0 N=1
www.asthmaustralia.org.au Click: Health Professionals GINA Guidelines (2014)
Resources
National Asthma Council Adult Acute Asthma Guidelines 11/4/15 114 N=113 N=1
(aged 16 years and older)

Australia Reasons for exclusion: Asthma Booklet


www.nationalasthma.org.au 2014 Asthma Management ??PDF Availability
Handbook- not guidelines (contact emailed)

Australia Medical Association “asthma management” 11/4/15 19 N=19 N=0


www.ama.com.au Reasons for exclusion:
2014 Asthma handbook for
GP use; Asthma management
plan; Asthma treatment
| Management of an Acute Asthma Attack in Adults
71
Organisations Search Term Date Hits Screen for eligibility Screen for eligibility 72
of search EXCLUDE INCLUDE
GINA - Global Information Asthma management 11/4/15 87 N=85 N=2
Network on Asthma (GINA) Reasons for exclusion: • GINA 2012 guideline
www.ginasthma.org 2015 pocket guide • GINA 2015
Children’s pocket guide
(global strategy for
management and prevention)
World Allergy Organization “asthma management” 11/4/15 118 N=118 N= 0
(WAO) Reasons for exclusion:
www.worldalergy.org GINA 2002;
(aged 16 years and older)

NAEPP 1997;
Journals not guidelines (GINA
guidelines mentioned);
2011 WAO White Book on
Allergies

World Health Organisation “asthma management” 12/4/15 30 N=30 N=0


(WHO) Reasons for exclusion:
www.who.int/en GARD reports out of date
| Management of an Acute Asthma Attack in Adults

(2004/2005);
Tobacco Control Guideline
International Primary Care Adult Acute Asthma Guidelines 12/4/15 58 N=58 N=0
Respiratory Group (IPCRG) All journal publications
www.theipcrg.org however; GINA/NICE/BTS
mentioned in same
BTS/SIGN mentioned for
children guidelines
Global Allergy and Asthma No Search Box 12/4/15 2 N= 0 N=2
Patient Platform(GAAPP) Click: Links • GINA 2014
www.ga2p2.org Click: Guideline Organizations • ARIA 2008 (OUT OF DATE)

Allergic Rhinitis and it Impact No Search Box 12/4/15 1 N=1 N=0


on Asthma (ARIA) Click: ARIA guidelines 2008 ARIA pocket guide
www.whair.org (OUT OF DATE)
| A National Clinical Guideline
Organisations Search Term Date Hits Screen for eligibility Screen for eligibility
of search EXCLUDE INCLUDE
Global Alliance Against Adult Acute Asthma Guidelines 12/4/15 203 N=203 N=0
Chronic Respiratory Disease GARD ‘basket’ Guidelines
(GARD) Document (2008) (OUT OF DATE)
www.who.int/resp/gard/en
Thoracic Societies
British Thoracic Society (BTS) Adult acute asthma guidelines 11/4/15 25 N=18 N=7
https://www.brit-thoracic. Reasons for exclusion:
| A National Clinical Guideline

org.uk/ Advisory groups only • NICE standards


Guidelines on pneumonia/ TB • Adult Asthma Audit 2012
• BTS/SIGN Guidelines
• ARIA guidelines (OUT OF
DATE)
American Thoracic Society Adult asthma guidelines 2015 11/04/15 292 N= 291 N=1
(ATS) Reasons for exclusion: journals
http://www.thoracic.org/ only- Journal includes discussion
Guidelines mentioned in with reference to: ERS/ATS
journals are: ERS/ATS guidelines
Canadian Thoracic Society/ Asthma Management 12/4/15 11 N=10 N=1
Respiratory Guidelines (CTS) Reasons for exclusion:
www.respiratoryguidelines. Journal references only; GINA guidelines
ca Professional development
courses for asthma
management
Irish Thoracic Society (ITS) No Search Box 11/4/15 None ITS report on Home Page (2008) N=0
(aged 16 years and older)

www.irishthoracicsociety.
com
Scottish Thoracic Society Adult acute asthma guidelines 11/4/15 5 N=5 N=0
(STS) Reasons for exclusion:
www.sts.rcpe.ac.uk No guidelines
However, ATS/BLF/BTS/
ERS all mentioned
The Thoracic Society of Adult acute asthma guidelines 11/4/15 69 N=69 N=0
Australia and New Zealand 2006 guidelines only
| Management of an Acute Asthma Attack in Adults

2006 handbook (OUT OF DATE)


73
Organisations Search Term Date Hits Screen for eligibility Screen for eligibility 74
of search EXCLUDE INCLUDE
Lung Associations
American Lung Association Clinical Practice Adult Asthma 11/4/15 77 N=76 N=1
(ALA) Guidelines Reasons for exclusion: Reasons:
http://www.lung.org/lung- Address topics of importance Alaska Asthma Plan 2006-2011
disease/ relating to asthma care (i.e. includes reference to GINA/
Tobacco control) NHLBI guidelines (2014)
State by State Asthma Action
Plans
No Clinical Guidelines evident
(aged 16 years and older)

The Lung Association Ontario “asthma management” 12/4/15 20 N= 19 N=1


www.on.lung.ca Reasons for exclusion: Emergency Department
School provider education Asthma Care Pathway (EDACP)
program for asthma March 2013-
management Bases the pathway on CTS
Asthma Handbook guidelines
Asthma Action Plans for parents
The Lung Association Asthma Management 12/4/15 16 N=15 N=1
www.lung.ca Reasons for exclusion: GINA guideline (2014)
| Management of an Acute Asthma Attack in Adults

Asthma action plans; asthma


education; asthma at work;
asthma and spirometry
Outputs Hits Exclude Potentially eligible (first screen
1924 1892 = 32

Second Screen
Exclude 29
Include 3
(SIGN/BTS; GINA; AUSTRALIAN
HANDBOOK)
| A National Clinical Guideline
Appendix 3.3 Grey literature databases

Grey Literature Search Terms Dates Hits Screen for eligibility Screen for eligibility
Databases EXCLUDE INCLUDE
Agency for Healthcare Advanced Search 10/04/2015 N=261 N=261 N=0
Research and Quality With all the words:
http://www.ahrq.gov/ adult acute asthma Reasons for exclusion –
management same
With the exact phrase:
"guideline" Quality improvement
| A National Clinical Guideline

Limited to English as opposed to a


language and guideline
filetype:pdf
Return results where
terms appear
anywhere in the page

Click on Health care


information – topics
A-Z – topic asthma – for
professionals
Open Grey Asthma guidelines 10/04/2015 N=11 N=11 N=0
http://www.opengrey.
eu/ Adult acute asthma N=4 N=4 N=0
+guidelines
Outputs Hits 276 Exclude 276 Include 0
(aged 16 years and older)
| Management of an Acute Asthma Attack in Adults
75
| Management of an Acute Asthma Attack in Adults | A National Clinical Guideline
76 (aged 16 years and older)

Appendix 3.4. Electronic databases

ID Search terms Medline CINAHL PUBMED


#1 Asthma (MH+) 107,073 24627 107092
#2 Asthma (keyword) 143,572 28506 140458
#3 Acute asthma (keyword) 2932 785 2932
#4 Acute asthma exacerbations (keyword) 255 88 255
#5 Uncontrolled asthma (keyword) 602 136 602
#6 Severe asthma (keyword) 5187 966 5182
#7 Life threatening asthma (keyword) 194 57 192
#8 Near fatal asthma (keyword) 181 36 181
#9 Status asthmaticus (MH) 1040 225 1684
#10 OR/#1-9 143837 28616 140811
#11 adult (MH+) 5665024 1145736 5667848
#12 Adult (keyword) 4444059 776697 4439961
#13 Adult patient (keyword) 4591 876 4593
#14 OR/#11-13 6015758 1171670 6012229
#15 Assessment (keyword) 922294 346611 914280
#16 Monitoring (keyword) 459208 69398 456690
#17 Diagnosis (MH+) 6610890 1121029 6612465
#18 Treatment (keyword) 3506610 521017 3498250
#19 Management 917757 (KW) 9978 (MH) 875672 (tw)
#20 Inhalers (keyword) 3475 678 3475
#21 Pharmacological management (kw) 1621 547 1620
#22 Non-pharmacological management 163 67 0
#23 Self-management (kw) 9718 6002 9636
#24 Control (kw) 3010710 608387 2959051
#25 Quality of life (MH) 122714 62463 122760
#26 Self-care (MH) 24236 24372 40854
#27 Morbidity (MH) 23524 5683 383046
#28 Mortality (MH) 34519 17348 288028
#29 OR/#15-28 11310825 1842154 11434890
#30 Hospitalization (MH +) 164757 62705 164805
#31 Patient admission (MH) 18979 10840 18982
#32 Patient discharge (MH) 19637 10395 19647
#33 Acute adult hospital (kw) 3 2 0
#34 Emergency medicine (MH) 10153 7367 10153
#35 Emergency medical services (MH +) 98675 66913 98725
#36 Emergency Service, Hospital 51482 (MH+) 2 (kw) 51517
#37 Primary health care 82009 (MH+) 40805 (MH) 82048
#38 Primary care (kw) 91294 37157 77262
#39 General practitioners 2318 7074 2319 (MH)
(MH) (kw)
#40 Family practice (MH) 60116 18355 60116
#41 Physicians, family 14773 12163 14733
#42 Allied health personnel (MH +) 42381 84759 42385
| A National Clinical Guideline | Management of an Acute Asthma Attack in Adults
(aged 16 years and older) 77

ID Search terms Medline CINAHL PUBMED


#43 Emergency medical technicians (MH) 4909 8577 4909
#44 OR/#30-43 481679 302166 462294
#45 AND/10+14+29+44 2845 1105 2848
Limiters
2627 576 (dates
(eng applied)
language)
Note: These were all screened from here down. 558 (date 345 (date 541 (English
and and language)
language) language
limiters
applied)
Limiter - guideline 0 2 1
0 0 0
| Management of an Acute Asthma Attack in Adults | A National Clinical Guideline
78 (aged 16 years and older)

Appendix 3.5 Internet search engines

Internet search Search Term Date Screened Outputs


engine of search
Google Advanced Search 11/04/2015 First 10 New York State Dept. of Health
All these words: asthma pages Guidelines (exclude – not a
management in adults n=100 national guideline)
This exact word or phrase: pdf files
“guideline” NICE Asthma Quality Standard
Limited to: English – 2015 Consultation document
language and file type [?standard as opposed to an
pdf evidence based guideline
exclude]

NHLBI Asthma Care Quick


Reference 2012 [relates to NHLBI
2007 guideline which is outside
our inclusion date and this is not
a specific guideline]

Japanese Guideline for adult


asthma 2014 published paper
[limited methodological
information authors emailed]

SINA (Saudi Initiative for Asthma)


Bing ("adult asthma 11/04/2015 First 10 No guidelines retrieved that did
management") pages not already have
("guideline") (file type: pdf) n=100
Narrowed: English pdf files
language
Yahoo/Alta ("guidelines for 11/04/2015 First 10 South African Asthma Guideline
Vista management of asthma") pages 2013 (based on GINA – exclude)
(pdf) n=100
pdf files
Outputs Hits First Screen
reviewed Exclude 294
n=300 Potentially eligible 6

Second Screen
Exclude 6
[but waiting for Japanese –
authors response]
| A National Clinical Guideline | Management of an Acute Asthma Attack in Adults
(aged 16 years and older) 79

Points to note about the internet search engine searches


• Various combination of search terms etc. were tried before settled on the search terms, as outlined
above. These search terms were populating the best results in terms of retrieving guidelines.
• If available, these searches were all narrowed to the English language and limited to the file type pdf,
so as to make the search / screening manageable.
• As large volumes of data return through search engine searches screening was managed by
screening the first 10 pages (i.e. 100 pdf files on each internet search engine);
• These internet searches were completed after all other searches and essentially we were looking
for any guidelines that we had not already retrieved to other sources. The valuable aspect of these
internet searches were that we were getting back all the guidelines which we had already sourced
and the majority of these were coming up in the first 10-20 hits.
• What we noted from these searches was that the most relevant national guidelines were coming up
in the first 10-20 hits after this the next few papers moved into more local guidelines (as opposed to
national) many of which drew on the recommendations of the national retrieved guidelines.
• Reasons for exclusion – chronic asthma, occupational asthma, not national guideline, not systematic
evidence based guideline, published outside inclusion criteria publication date.
Appendix 4: Characteristics of retrieved guidelines 80

Title/Reference Publisher Country, Publication End of search date Comments


language date
Asthma: diagnosis and monitoring NICE UK, English Draft consult Is this a standard as opposed
of asthma in adults, children and National Institute for Jan 2015 to a guideline?
young people Health and Care It is also just a draft for
Excellence consultation

EXCLUDE
Australian Asthma Handbook 2014 National Asthma Australia Updated TBC – site states search INCLUDE??
(aged 16 years and older)

Council Australia English April 2015 information to follow Association emailed to try
http://www.asthmahandbook.org. (minor get pdf version…..
au/ update
to version Follow up – missing data;
March 2014) plus also limited data on
‘acute’ asthma
First
Published EXCLUDE
1990
Clinical Guideline for the Diagnosis, New York State Dept. Updated Not a national guideline
| Management of an Acute Asthma Attack in Adults

Evaluation and Management of of Health July 2013 No reporting of systematic


Adults and Children with Asthma. methodology/evidence

EXCLUDE
Consensus Statement for the Canadian Thoracic Canada, Updated June 2010 (for This is a published paper
diagnosis and management of Society English 2012 literature) on the update of 4 key
asthma questions; literature search
First Oct 2010 (for ended 2010
(Lougheed MD, Lemiere C, published systematic reviews) INCLUDE?
Ducharme FM, Licskai C, Dell 2010 Following discussion with
SD, Rowe BH, itzgerald M, Leigh GDG – this more focused on
R, Watson W, Louis-Philippe B, chronic asthma not ‘acute’
Canadian Thoracic Society Asthma
Clinical Assembly. Can Respir J. EXCLUDE
2012. 19(2):127-164)
| A National Clinical Guideline
Title/Reference Publisher Country, Publication End of search date Comments
language date
Diagnosis and Management of ICSI Bloomington, Updated Nov 2011 (for Not a national guideline
Asthma Institute for Clinical Minnesota 2012 systematic reviews)
Systems Improvement English EXCLUDE
(Sveum R, Bergstrom J, Brottman First March 2012 (for patient
G, Hanson M, Heiman M, Johns published education and self-
K, Malkiewicz J, Manney S, Moyer 1994 management)
L, Myers C, Myers N, O’Brien M,
Rethwill M, Schaefer K, Uden
D. Institute for Clinical Systems
| A National Clinical Guideline

Improvement. Diagnosis and


Management of Asthma. Updated
July 2012)
Guidelines for the Diagnosis and National Heart, Lung US, English July 2007 Outside of our inclusion
Management of Asthma (EPR-3) and Blood Institute criteria for publication date

EXCLUDE
Guideline for the management of South African South Africa Updated These guidelines are based
acute asthma in adults Thoracic Society English 2013 on GINA

(South African Medical Journal First EXCLUDE


March 2013: 102(3):190-198) published
1994
Global Strategy for Asthma Global Initiative for International Updated Routine twice
Management and Prevention Asthma (GINA) English 2015 yearly review of INCLUDE
literature by GINA
(From the Global Strategy for First scientific committee
Asthma Management and published (publication Jan 1to
(aged 16 years and older)

Prevention, Global Initiative for 2002 June 30 reviewed


Asthma (GINA) 2015. Available at ERS meeting and
from: http://www.ginasthma.org/) July 1-Dec 30 at ATS
meeting)
| Management of an Acute Asthma Attack in Adults
81
Title/Reference Publisher Country, Publication End of search date Comments 82
language date
General principles for the diagnosis Michigan Quality Michigan, US Updated 2012 Not a national guideline
and management of asthma Improvement English 2012
Consortium EXCLUDE
(Michigan Quality Improvement
Consortium. General principles for
the diagnosis and management of
asthma. Southfield (MI): Michigan
Quality Improvement Consortium;
2012 Jul. 1 p.)
http://www.guideline.gov/content.
(aged 16 years and older)

aspx?id=38693
International ERS/ATS guidelines on ERS/ATS International Published Not acute asthma
definition, evaluation and treatment European Respiratory English 2014 (confirmed with P Manning)
of severe asthma Society/American
Thoracic Society EXCLUDE
(Chung et al. 2014 Eur Respir J
43:343-373)
Japanese Guideline for Adult Japanese Society of Japan Updated Limited information on
Asthma 2014 Allergology English 2014 methodology in terms of
| Management of an Acute Asthma Attack in Adults

(Allergology International 2014; publication guideline development


63:293-333) and grading of evidence –
authors emailed (response
awaited)

EXCLUDE
Quality Standard for Asthma NICE National UK, English Last Is this a standard as opposed
Institute for Health modified to a guideline?
and Care Excellence Feb 2013 Also standards seem to be
informed/underpinned by
BTS/SIGN asthma guideline

EXCLUDE
| A National Clinical Guideline
Title/Reference Publisher Country, Publication End of search date Comments
language date
Saudi Initiative for asthma – 2012 Saudi Initiative for Saudi, Updated The paper states that This guideline is based on
update: guidelines for the diagnosis Asthma (SINA) English 2012 the updated guidelines other guidelines – GINA and
and management of asthma in followed the same NAEPP
adults and children methodology as the
original guidelines EXCLUDE
(Al-Moamary et al. 2012. Annals of
Thoracic Medicine. 7(4):175-204)
SIGN 141. British guideline on the SIGN/BTA Britain, English Updated Searches conducted
| A National Clinical Guideline

management of asthma: a national Scottish 2014 on a rolling basis. INCLUDE


clinical guideline. Intercollegiate Diagnosis in adults
Guideline Network/ First (Feb 2010); non-
British Thoracic published pharmacological
Society 2003 management
(Feb 2006);
pharmacological
management
(Feb 2010); inhaler
devices (Jun 2008);
management of acute
asthma (June 2008);
asthma in pregnancy
(June 2008); patient
education and self-
management (Feb
2006)
(aged 16 years and older)
| Management of an Acute Asthma Attack in Adults
83
| Management of an Acute Asthma Attack in Adults | A National Clinical Guideline
84 (aged 16 years and older)

Appendix 5: Sample – AGREE II Instrument


Partial Extract - AGREE II Instrument (Brouwers et al. 2010 (12))

DOMAIN 1. SCOPE AND PURPOSE

 
 
1. The overall objective(s) of the guideline is (are) specifically described.
 
 
1   7  
2   3   4     5   6  
Strongly  Disagree     Strongly   Agree  
   
Comments  
   
   
   
   
 
 
2. The health question(s) covered by the guideline   is (are) specifically described.
 
1     7  
2   3   4     5   6  
Strongly  Disagree   Strongly  Agree  
 
 
Comments
 
 
 
 
 
 
 
 
 
 
 
3. The population (patients, public, etc.) to whom   the guideline is meant to apply is
specifically described.  
 
1   7  
2   3   4     5   6  
Strongly  Disagree     Strongly  Agree  
 
Comments  
   
   
     
   
 
 
DOMAIN 2. STAKEHOLDER INVOLVEMENT
 
 

     
2     individuals from all relevant professional
  4. The guideline development group includes  
groups.and preferences have been sought.
views
 
1     7  
2   3  
4     5   6  
Strongly  Disagree   Strongly  Agree  
 
Comments
 
   
   
   
   
 
 
5. The views and preferences of the target population (patients, public, etc.) have been
 
sought.
 
 
1   7  
2   3   4     5   6  
Strongly  Disagree     Strongly  Agree  
 
Comments  
 
 
   
   
| A National Clinical Guideline | Management of an Acute Asthma Attack in Adults
(aged 16 years and older) 85

Appendix 6: Protocol for guideline appraisal training phase

Guideline  review:  adult  acute  asthma  


management    
Strand  2:  Assessment  of  Guideline  
Quality    
 
Phase  (a)  Guideline  Appraisal  Training  
 
PROTOCOL  
Prepared  by  Dr  Veronica  Lambert  DCU  

The  Guideline  for  Appraisal  is…..  

*  The  guideline  for  conduct  


of  the  appraisal  training  
phase  (pilot)  is  the     *  You  will  also  need  to  review  the  
electronic  version  which  is  
*  British  guideline  on  the   available  at  the  following  link  
management  of  asthma   *  http://www.sign.ac.uk/
(SIGN/BTA  2014)   guidelines/fulltext/141/
*  We  will  circulate  a  hard   index.html  
copy  of  the  main  SIGN/BTA   *  This  is  important  for  accessing  
guideline  document  [and   supplemental  information  such  
make  it  available  through  our   as  search  strategies  and  
shared  folder  in  Google  Drive];   evidence  tables;  which  are  not  
however…..   always  published  in  the  main  
guideline  document  

The  Guideline  Appraisal  tool  is…AGREE  II  

*  We  will  circulate  a  hard  copy  


of  AGREE  II  MANUAL  [and  
make  it  available  on  our  shared  
folder  in  Google  Drive]    
*  The  Manual  can  also  be  
accessed  through  the  
following  link  
http://www.agreetrust.org/  
| Management of an Acute Asthma Attack in Adults | A National Clinical Guideline
86 (aged 16 years and older)

Who  are  the  Reviewers?…..  

*  The  AGREE  II  instructions  recommends  at  least  2  but  


preferably  4  reviewers    
*  In  line  with  this  and  as  per  tender  document  we  
propose  that  we  have  4  reviewers  to  increase  the  
reliability  of  the  assessment  
*  2  DCU  reviewers  =  V  Lambert  &  A  Matthews  
*  2  Asthma  GDG  reviewers  =  P  Manning  &  S  Lane  (TBC)  

 What  are  our  timelines?.....  

*  The  timeline  for  completion  of  this  training  appraisal  (pilot)  


of  the  SIGN/BTA  guideline  is  1  week;  all  reviewers  must  
submit  their  appraisal  of  the  SIGN/BTA  guideline  to  
Veronica  on/before  close  of  business  on  Wednesday  22nd  
April  
*  Following  this,  in  week  3  (22nd-­‐29th  April),  the  appraisals  of  
the  remaining  3  guidelines  considered  as  eligible  for  inclusion  
in  the  review  must  be  completed  by  the  reviewers  on/before  
close  of  business  on  Wednesday  29th  April  

What  is  the  time  commitment  required  


to  complete  the  training  appraisal?…..  

*  Drawing  on  the  AGREE  II  training  tools  it  is  suggested  that  at  minimum  2-­‐2.5  
hours  should  be  factored  in  to  complete  the  entire  appraisal  of  the  SIGN/BTA  
guideline.    
*  It  is  important  to  factor  in  time  for  the  following  elements;  
*  Reading  the  entire  SIGN/BTA  guideline  document    
*  Participation  in  online  training  (details  to  follow  on  next  slide)    
*  Reading  of  the  AGREE  II  Manual    
*  Completion  of  the  guideline  document  appraisal    
*  Note:  some  of  these  tasks  may  be  conducted  concurrently  such  as  participating  in  
online  training  and  reading  the  manual;  and  the  appraisal  could  be  done  in  steps  
according  to  the  domains  of  the  AGREE  II  Instrument  if  time  needed  to  be  broken  up  
*  Note:  This  time  will  also  need  to  be  factored  in  for  appraising  the  other  3  guidelines  in  week  
3  (22nd-­‐29th  April);  the  time  per  evaluating  each  document  might  be  slightly  less  due  to  
familiarity  with  the  appraisal  tool/process  following  the  training  appraisal  e.g.  1-­‐1.5  hours  
per  each  guideline  (i.e.  3-­‐4.5  hours  for  the  final  3  guideline  documents)  
| A National Clinical Guideline | Management of an Acute Asthma Attack in Adults
(aged 16 years and older) 87

STEP  1……Read  the  guideline    

*  Read  the  SIGN/BTA  clinical  practice  guideline  


document  in  full  and  obtain  all  related  information  
and  needed  documents  before  undertaking  the  
AGREE  II  assessment    

Step  2…Participate  in  online  training    

*  Alongside  the  AGREE  II  User’s  Instruction  Manual  (referred  to  


earlier  and  circulated),  AGREE  II  have  a  number  of  online  
training  tools;  accessible  @  
http://www.agreetrust.org/resource-­‐centre/agree-­‐ii-­‐training-­‐
tools/  
*  AGREE  II  overview  tutorial  (10mins)  
*  AGREE  II  tutorial  and  practical  exercise  (1  hour  –  note  this  is  a  
practice  exercise  in  appraising  a  guideline  and  could  be  used  as  an  
additional  resource  should  you  feel  you  need  to  do  a  trial  run  
before  you  appraise  the  SIGN/BTS  guideline)  

STEP  3….Read  the  AGREE  II  Manual  

*  After  completing  the  online  training  you  should  be  somewhat  


familiar  with  the  AGREE  II  Instrument  
*  Following  this,  use  the  User’s  Manual  to  help  you  as  you  complete  
the  guideline  appraisal  
*  Hopefully  the  next  few  slides  will  help  you  with  this  and  guide  you  
to  the  relevant  resources;  and  what  exactly  you  need  to  become  
familiar  with;  including  
*  The  core  DOMAINS  and  OVERALL  ASSESSMENT  items  of  the  AGREE  II  
instrument    
*  The  AGREE  II  -­‐  RATING  SCALE  (and  what  this  means)  
| Management of an Acute Asthma Attack in Adults | A National Clinical Guideline
88 (aged 16 years and older)

The  AGREE  II  includes…..  


6  Domains  &  2  Overall  Assessment  Ratings  

*  23  core  items  …..  


*  2  global  rating  items  (i.e.  overall  assessment)……  
*  23  items  in  6  domains  (User’s  Manual  page  10  overview)  
No   Domain   No.  of  items   Manual  page  
1   Scope  and  Purpose   3   p.14-­‐17  
2   Stakeholder  Involvement     3   p.18-­‐21  
3   Rigour  of  Development     8   p.22-­‐30  
4   Clarity  of  Presentation   4   p.31-­‐34  
5   Applicability     3   p.35-­‐39  
6   Editorial  Independence     2   p.40-­‐42  
OVERALL  GUIDELINE  ASSESSMENT   2   P.43-­‐44  

Example:  Domain  1  Scope  and  Purpose    

Overall  Guideline  Assessment    

*  The  overall  assessment  requires  the  you  to  make  a  


judgment  as  to  the  quality  of  the  guideline,  taking  
into  account  the  criteria  considered  in  the  assessment  
process  
*  You  are  also  asked  whether  you  recommend  use  of  
the  guideline  
| A National Clinical Guideline | Management of an Acute Asthma Attack in Adults
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Overall  Guideline  Assessment  

THE  7-­‐point  RATING  SCALE    


*  All  AGREE  II  items  are  rated  on  the  following  7-­‐point  scale    

Score   Meaning  

7  (strongly  agree)   The  quality  of  reporting  is  exceptional  


Full  CRITERIA  and  CONSIDERATIONS  are  met    
(see  User’s  Manual  on  ‘HOW  TO  RATE’  p.  11  &  slide  to  follow)  
1  (strongly  disagree)   No  information  relevant  to  AGREE  II  item  OR  the  concept  is  
very  poorly  reported    
2-­‐6   The  reporting  of  the  item  does  not  meet  the  full  CRITERIA  
or  CONSIDERATIONS,  depending  on  the  completeness  and  
quality  of  reporting.  Scores  increase  as  more  criteria  are  
met  and  considerations  addressed.  

For  each  Domain  there  is  guidance  for  


rating  the  23  items…..  
You  will  need  to  follow  the  User’s  Manual  pages  11-­‐41  
First  READ  PAGE  11  of  the  User’s  Manual  which  gives  you  details  on  3  
additional  sections  to  facilitate  your  assessment    

q User’s  Manual  Description    


Ø  (i.e.  this  section  defines  the  item  concept  and  provides  examples)  
q Where  to  Look  
Ø  (i.e.  this  section  directs  the  appraiser  to  where  the  information  to  rate  the  
item  might  be  found  in  the  guideline  document)  
q How  to  Rate    
Ø  (i.e.  this  sections  gives  details  on  the  assessment  CRITERIA  and  
CONSIDERATIONS  specific  to  each  item)  
v  CRITERIA  –  reflect  the  operational  definition  of  the  item;  the  more  criteria  
that  are  met  the  higher  the  rating  for  that  item  
v  CONSIDERATIONS  –  are  to  help  inform  the  assessment;  the  more  criteria  
that  are  met  the  higher  the  rating  for  that  item  
| Management of an Acute Asthma Attack in Adults | A National Clinical Guideline
90 (aged 16 years and older)

*  Example  of  
q User’s  Manual  
Description    
q Where  to  Look  
q How  to  Rate    
*  For  item  1  Domain  1  
(scope  and  
purpose)    
*  (p.15  AGREE  II  
User’s  Manual)  
| A National Clinical Guideline | Management of an Acute Asthma Attack in Adults
(aged 16 years and older) 91

Appendix 7: MY AGREE PLUS


http://www.agreetrust.org/
| Management of an Acute Asthma Attack in Adults | A National Clinical Guideline
92 (aged 16 years and older)

Appendix 8: Quality appraisal visual graphs


(overall scores and inter-rater agreement)

Domains – overview – both guidelines

Scope  and  
100   purpose  
Stakeholder  
80   involvment  
Rigour  of  
60  
development  
40   Clariy  of  
presentaFon  
20   Applicability  

0   Editorial  
BTS/SIGN   GINA   independence  
Overall  
Guideline   Guideline  
assessment  

Domains – overview – both guidelines

100  
90  
80  
70  
60  
50  
40  
30   BTS/SIGN  
20  
10   Guideline  
0  
GINA  Guideline  
re pm t  

1  
 o ve me  

pe bi  
en  
OA  
l  in pp aC  
ity e ve e

de lica on
nd lity

 
ria A ent ent

ce
f  p lo n
ar f  d ol os
Cl r  o  inv urp
p
go er d  

s
Ri old  an
eh pe
ak Sco

ito
Ed
St
| A National Clinical Guideline | Management of an Acute Asthma Attack in Adults
(aged 16 years and older) 93

BTS/SIGN Guideline

BTS/SIGN – Domain 1: Scope and Purpose

7  
6  
5  
4  
3   Item  1  
2   Item  2  
1  
Item  3  
0  
 

 
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Ap

Ap

BTS/SIGN – Domain 2: Stakeholder Involvement

7  
6  
5  
4  
3   Item  4  
2   Item  5  
1   Item  6  
0  
 

 
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| Management of an Acute Asthma Attack in Adults | A National Clinical Guideline
94 (aged 16 years and older)

BTS/SIGN – Domain 3: Rigour of Development

7  
6   Item  7  
5   Item  8  
4   Item  9  
3   Item  10  
2  
Item  11  
1  
Item  12  
0  
Item  13  
 

 
r  1

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Item  14  
se

se

se

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ai

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Ap

Ap

Ap

BTS/SIGN – Domain 4: Clarity of presentation

7  
6  
5  
4  
Item  15  
3  
2   Item  16  
1   Item  17  
0  
 

 
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ise

ise

ise

ise
a

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BTS/SIGN – Domain 5: Applicability

7  
6  
5  
4   Item  18  
3   Item  19  
2  
Item  20  
1  
0   Item  21  
 

 
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Ap

Ap

BTS/SIGN – Domain 6: Editorial Independence

7  
6  
5  
4  
3   Item  22  
2  
Item  23  
1  
0  
 

 
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Ap
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96 (aged 16 years and older)

BTS/SIGN - Overall Assessment

8  
6  
4  
2  
0  
 

 
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Ap

Ap

GINA Guideline
GINA – Domain 1: Scope and Purpose

7  
6  
5  
4  
3   Item  1  
2   Item  2  
1  
Item  3  
0  
 

 
r  1

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| A National Clinical Guideline | Management of an Acute Asthma Attack in Adults
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GINA – Domain 2: Stakeholder Involvement

7  
6  
5  
4  
3   Item  4  
2   Item  5  
1  
Item  6  
0  
 

 
r  1

r  2

r  3

r  4
se

se

se

se
ai

ai

ai

ai
pr

pr

pr

pr
Ap

Ap

Ap

Ap

GINA – Domain 3: Rigour of Development

7  
6   Item  7  
5   Item  8  
4   Item  9  
3   Item  10  
2  
Item  11  
1  
Item  12  
0  
Item  13  
 

 
r  1

r  2

r  3

r  4
se

se

se

se

Item  14  
ai

ai

ai

ai
pr

pr

pr

pr
Ap

Ap

Ap

Ap
| Management of an Acute Asthma Attack in Adults | A National Clinical Guideline
98 (aged 16 years and older)

GINA – Domain 4: Clarity of Presentation

7  
6  
5  
4  
3   Item  15  
2   Item  16  
1   Item  17  
0  
 

 
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r  2

r  3

r  4
se

se

se

se
ai

ai

ai

ai
pr

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pr

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Ap

Ap

Ap

GINA – Domain 5: Applicability

7  
6  
5  
4   Item  18  
3   Item  19  
2   Item  20  
1  
Item  21  
0  
 

 
r  1

r  2

r  3

r  4
se

se

se

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ai

ai

ai

ai
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Ap

Ap

Ap
| A National Clinical Guideline | Management of an Acute Asthma Attack in Adults
(aged 16 years and older) 99

GINA – Domain 6: Editorial Independence

7  
6  
5  
4  
3   Item  22  
2  
1   Item  23  
0  
 

 
r  1

r  2

r  3

r  4
se

se

se

se
ai

ai

ai

ai
pr

pr

pr

pr
Ap

Ap

Ap

Ap

GINA - Overall Assessment

7  
6  
5  
4  
3  
2    
1  
0  
 

 
r  1

r  2

r  3

r  4
ise

ise

ise

ise
a

a
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pr

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Ap

Ap

Ap
| Management of an Acute Asthma Attack in Adults | A National Clinical Guideline
100 (aged 16 years and older)

Appendix 9: Revisions to quality appraisal visual graphs


(overall scores and inter-rater agreement)

Domains – overview – both guidelines

100   Scope  and  


90   purpose  
80   Stakeholder  
involvment  
70  
Rigour  of  
60   development  
50   Clarity  of  
40   presentaJon  
30   Applicability  
20  
Editorial  
10   independence  
0   Overall  
BTS/SIGN   GINA   assessment  
Guideline   Guideline  
| A National Clinical Guideline | Management of an Acute Asthma Attack in Adults
(aged 16 years and older) 101

Domains – overview – both guidelines

100  
90  
80  
70  
60  
50  
40   BTS/SIGN  
30   Guideline  
20   GINA  Guideline  
10  
0  
t
ria A ent nt  
ity e em e  

Ov de lica on  

es e    
l a e  
re pm t  

en
al nd ty
f  p lo n
ar f  d lv s

ss nc
er pe bili

sm
s e
 o ve e
Cl r  o invo urpo

l  in pp aC
go er  p
Ri old  and
u  
eh pe
ak Sco

ito
Ed
St
| Management of an Acute Asthma Attack in Adults | A National Clinical Guideline
102 (aged 16 years and older)

BTS/SIGN Guideline
BTS/SIGN – Domain 1: Scope and Purpose

7  
6  
5  
4  
3   Item  1  
2   Item  2  
1  
0   Item  3  
 

 
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Ap

Ap

BTS/SIGN – Domain 2: Stakeholder Involvement

7  
6  
5  
4  
3   Item  4  
2   Item  5  
1   Item  6  
0  
 

 
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BTS/SIGN – Domain 3: Rigour of Development

7  
6   Item  7  
5   Item  8  
4   Item  9  
3   Item  10  
2  
Item  11  
1  
Item  12  
0  
Item  13  
 

 
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r  3

r  4
Item  14  
se

se

se

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ai

ai

ai

ai
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Ap

Ap

Ap

BTS/SIGN – Domain 4: Clarity of presentation

7  
6  
5  
4  
3   Item  15  
2   Item  16  
1   Item  17  
0  
 

 
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BTS/SIGN – Domain 5: Applicability

7  
6  
5  
4   Item  18  
3   Item  19  
2  
1   Item  20  
0   Item  21  
 

 
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Ap

Ap

BTS/SIGN – Domain 6: Editorial Independence

7  
6  
5  
4  
3   Item  22  
2  
Item  23  
1  
0  
 

 
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BTS/SIGN - Overall Assessment

7  
6  
5  
4  
3  
2    
1  
0  
 

 
r  1

r  2

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Ap

Ap

GINA Guideline
GINA – Domain 1: Scope and Purpose

7  
6  
5  
4  
3   Item  1  
2   Item  2  
1  
Item  3  
0  
 

 
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106 (aged 16 years and older)

GINA – Domain 2: Stakeholder Involvement

7  
6  
5  
4  
3   Item  4  
2   Item  5  
1   Item  6  
0  
 

 
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Ap

Ap

GINA – Domain 3: Rigour of Development

7  
6   Item  7  
5   Item  8  
4   Item  9  
3   Item  10  
2  
Item  11  
1  
Item  12  
0  
Item  13  
 

 
r  1

r  2

r  3

r  4

Item  14  
ise

ise

ise

ise
a

a
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Ap

Ap

Ap
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GINA – Domain 4: Clarity of Presentation

7  
6  
5  
4  
Item  15  
3  
2   Item  16  
1   Item  17  
0  
 

 
r  1

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ai

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ai

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Ap

Ap

GINA – Domain 5: Applicability

7  
6  
5  
4   Item  18  
3   Item  19  
2   Item  20  
1   Item  21  
0  
 

 
r  1

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GINA – Domain 6: Editorial Independence

7  
6  
5  
4  
3   Item  22  
2  
Item  23  
1  
0  
 

 
r  1

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Ap

Ap

Ap

GINA - Overall Assessment

7  
6  
5  
4  
3  
2    
1  
0  
 

 
r  1

r  2

r  3

r  4
ise

ise

ise

ise
a

a
pr

pr

pr

pr
Ap

Ap

Ap

Ap
| A National Clinical Guideline | Management of an Acute Asthma Attack in Adults
(aged 16 years and older) 109

Appendix 10: Group consensus appraisal scores


Domain 1: Scope and Purpose (both BTS/SIGN and GINA)

7  
6  
5  
Item  1  
4  
Item  2  
3  
Item  3  
2  
1  
0  
BTS/SIGN   GINA  

Domain 2: Stakeholder Involvement (both BTS/SIGN and GINA)

7  
6  
5  
Item  4  
4  
Item  5  
3  
Item  6  
2  
1  
0  
BTS/SIGN   GINA  
| Management of an Acute Asthma Attack in Adults | A National Clinical Guideline
110 (aged 16 years and older)

Domain 3: Rigour of Development (both BTS/SIGN and GINA)

7   Item  7  
6   Item  8  
5   Item  9  
4   Item  10  
3   Item  11  
2   Item  12  
1  
Item  13  
0  
Item  14  
BTS/SIGN   GINA  

Domain 4: Clarity of Presentation (both BTS/SIGN and GINA)

7  
6  
5  
Item  15  
4  
Item  16  
3  
Item  17  
2  
1  
0  
BTS/SIGN   GINA  
| A National Clinical Guideline | Management of an Acute Asthma Attack in Adults
(aged 16 years and older) 111

Domain 5: Applicability (both BTS/SIGN and GINA)

7  
6  
5   Item  18  
4   Item  19  
3   Item  20  
2   Item  21  
1  
0  
BTS/SIGN   GINA  

Domain 6: Editorial Independence (both BTS/SIGN and GINA)

7  
6  
5  
4   Item  22  
3   Item  23  
2  
1  
0  
BTS/SIGN   GINA  
| Management of an Acute Asthma Attack in Adults | A National Clinical Guideline
112 (aged 16 years and older)

Domain 6: Overall Assessment (both BTS/SIGN and GINA)

7  
6  
5  
4    
3  
2  
1  
0  
BTS/SIGN   GINA  
| A National Clinical Guideline | Management of an Acute Asthma Attack in Adults
(aged 16 years and older) 113

Appendix 11: Description of grades of recommendations for each


guideline
Guideline BTS/SIGN BTS/SIGN GINA GINA

Recommendation Sources of evidence Description of level Sources of Description of level of


grade/level of evidence evidence evidence

A At least one meta- 1++ High quality RCTs and Evidence is from endpoints
analysis, systematic meta-analyses, meta-analyses. of well-designed RCTs or
Note: In BTS/SIGN review, or RCT rated systematic reviews Rich body of meta-analyses that provide a
this is referred to as as 1++, and directly of RCTs, or RCTs with evidence. consistent pattern of findings
GRADE A whereas in applicable to the a very low risk of in the population for which
GINA this is referred target population; or bias the recommendation is
to as EVIDENCE A A body of evidence made. Category A requires
consisting principally 1+ Well conducted substantial numbers of studies
of studies rated as 1+, meta-analyses, involving substantial numbers
directly applicable systematic reviews, of participants.
to the target or RCTs with a low
population, and risk of bias
demonstrating
overall consistency of 1 - Meta-analyses,
results systematic reviews,
or RCTs with a high
risk of bias

B A body of evidence 2++ High quality RCTs and meta- Evidence is from endpoints
including studies systematic reviews analyses. Limited of intervention studies that
Note: In BTS/SIGN rated as 2++, directly of case control or body of data. include only a limited number
this is referred to as applicable to the cohort studies of patients, post hoc or
GRADE B whereas in target population, High quality case subgroup analysis of RCTs or
GINA this is referred and demonstrating control or cohort meta-analysis of such RCTs. In
to as EVIDENCE B overall consistency of studies with a general, Category B pertains
results; or very low risk of when few randomised trials
Extrapolated confounding or exist, they are small in size,
evidence from bias and a high they were undertaken in a
studies rated as 1++ probability that the population that differs from
or 1+ relationship is the target population of
causal the recommendation, or
the results are somewhat
inconsistent.

C A body of evidence 2+ Well conducted Nonrandomised Evidence is from outcomes


including studies case control or trials. of uncontrolled or non-
Note: In BTS/SIGN rated as 2+, directly cohort studies Observational randomized trials or from
this is referred to as applicable to the with a low risk of studies. observational studies.
GRADE C whereas in target population confounding or bias
GINA this is referred and demonstrating and a moderate
to as EVIDENCE C overall consistency of probability that
results; or the relationship is
Extrapolated causal
evidence from
studies rated as 2++ 2 - Case control
or cohort studies
with a high risk of
confounding or bias
and a significant risk
that the relationship
is not causal
| Management of an Acute Asthma Attack in Adults | A National Clinical Guideline
114 (aged 16 years and older)

Guideline BTS/SIGN BTS/SIGN GINA GINA

D Evidence level 3 or 3 = non-analytic Panel consensus This category is used only in


4; or studies, eg case judgement. cases where the provision
Note: In BTS/SIGN Extrapolated reports, case series of some guidance was
this is referred to as evidence from deemed valuable but the
GRADE D whereas in studies rated as 2+ 4 = expert opinion clinical literature addressing
GINA this is referred the subject was insufficient
to as EVIDENCE D to justify placement in one
of the other categories. The
Panel Consensus is based
on clinical experience or
knowledge that does not
meet the above listed criteria.

Good practice point Recommended NA


best practice
based on the
clinical experience
of the guideline
development group
Appendix 12: Data extraction recommendation matrix
Context/Category BTS/SIGN - Recommendations GINA - Recommendations
Acute Asthma
Management
Adverse psychosocial Healthcare professionals must be aware that patients with
and behavioural factors severe asthma and one or more adverse psychosocial
factors are at risk of death (Grade B)
Patient at risk of near- Keep patients who have had a near-fatal asthma attack
| A National Clinical Guideline

fatal or fatal asthma under specialist supervision indefinitely (good practice


point)
Prediction and prevention A respiratory specialist should follow up patients admitted
of severe asthma attack with a severe asthma attack for at least one year after the
admission (good practice point)
Criteria for referral Refer to hospital any patients with features of acute severe
or life-threatening asthma (Grade D)
Criteria for admission Admit patients with any feature of a life-threatening or
near-fatal asthma attack (Grade B)

Admit patients with any feature of a severe asthma attack


persisting after initial treatment (Grade B)

Patients whose peak flow is greater than 75% best


or predicted one hour after initial treatment may be
discharged from ED unless they meet any of the following
criteria, when admission may be appropriate:
(aged 16 years and older)

• still have significant symptoms


• concerns about adherence
• living alone/socially isolated
• psychological problems
• physical disability or learning difficulties
• previous near-fatal asthma attack
• asthma attack despite adequate dose steroid tablets
pre-presentation
• presentation at night
• pregnancy (Grade C)
| Management of an Acute Asthma Attack in Adults
115
Context/Category BTS/SIGN - Recommendations GINA - Recommendations 116
Treatments - acute
asthma in adults
Oxygen Give supplementary oxygen to all hypoxemic patients with
acute severe asthma to maintain a SpO2 level of 94–98%.
Lack of pulse oximetry should not prevent the use of
oxygen (Grade C)
β2 agonist bronchodilators Use high-dose inhaled β2 agonists as first line agents in
patients with acute asthma and administer as early as
possible. Reserve intravenous β2 agonists for those patients
(aged 16 years and older)

in whom inhaled therapy cannot be used reliably (Grade


A).

In hospital, ambulance and primary care, nebulisers


for giving nebulised β2 agonist bronchodilators should
preferably be driven by oxygen (Grade A)

In patients with acute asthma with life-threatening features


the nebulised route (oxygen-driven) is recommended
(good practice point).
| Management of an Acute Asthma Attack in Adults

In severe asthma that is poorly responsive to an initial bolus


dose of β2 agonist, consider continuous nebulisation with an
appropriate nebulizer (Grade A)
Steroid therapy Give steroids in adequate doses in all cases of acute
asthma attack (Grade A)

Continue prednisolone 40–50 mg daily for at least five days


or until recovery (good practice point)
Ipratroprium Bromide Add nebulised ipratropium bromide (0.5 mg 4–6 hourly) to
β2 agonist treatment for patients with acute severe or life-
threatening asthma or those with a poor initial response to
β2 agonist therapy (Grade B)
| A National Clinical Guideline
Context/Category BTS/SIGN - Recommendations GINA - Recommendations
Magnesium Sulphate Nebulised magnesium sulphate is not recommended for
treatment in adults with acute asthma (Grade A)

Consider giving a single dose of IV magnesium sulphate


to patients with acute severe asthma (PEF <50% best or
predicted) who have not had a good initial response to
inhaled bronchodilator therapy (Grade B).

Magnesium sulphate (1.2–2 g IV infusion over 20 minutes)


should only be used following consultation with senior
| A National Clinical Guideline

medical staff (good practice point).


Intravenous aminophylline Use IV aminophylline only after consultation with senior
medical staff (good practice point)
Antibiotics Routine prescription of antibiotics is not indicated for
patients with acute asthma (Grade B)
Heliox Heliox is not recommended for use in patients with acute
asthma outside a clinical trial setting (Grade B)
Referral to Intensive Care In patients with acute severe or life-threatening asthma,
anaesthetists and intensivists should be notified as soon as
possible if there is no improvement in or deterioration of
asthma (good practice point)

All patients transferred to intensive care units should be


accompanied by a doctor suitably equipped and skilled to
intubate if necessary (Grade C)
Non-invasive ventilation Non-invasive ventilation (NIV) should only be considered in
(aged 16 years and older)

an ICU or equivalent clinical setting (good practice point)


| Management of an Acute Asthma Attack in Adults
117
Context/Category BTS/SIGN - Recommendations GINA - Recommendations 118
Further investigation and Measure and record PEF 15–30 minutes after starting
monitoring treatment, and thereafter according to the response.
Measure and record PEF before and after nebulised or
inhaled β2 agonist. (good practice point).

Record oxygen saturation by oximetry and maintain arterial


SpO2 at 94–98%. (good practice point).

Repeat measurements of blood gas tensions within one


hour of starting treatment if:
(aged 16 years and older)

• the initial PaO2 is <8 kPa unless SpO2 is >92%; or


• the initial PaCO2 is normal or raised; or
• the patient’s condition deteriorates (good practice
point)

Measure them again if the patient’s condition has not


improved by 4–6 hours (good practice point)

Measure and record the heart rate (good practice point)


| Management of an Acute Asthma Attack in Adults

Measure serum potassium and blood glucose


concentrations (good practice point)

Measure the serum theophylline concentration if


aminophylline is continued for more than 24 hours (aim
at a concentration of 10–20 mg/l or 55–110 mol/l) (good
practice point)
Follow Up It is essential that the patient’s primary care practice is
informed within 24 hours of discharge from the emergency
department or hospital following an asthma attack. Ideally
this communication should be directly with a named
individual responsible for asthma care within the practice,
by means of fax or email (good practice point)
β2 agonist delivery Inhaler
Devices
β2 agonist delivery - Adults with mild and moderate asthma attacks should be
Inhaler devices treated with a pMDI + spacer with doses titrated according
to clinical response (Grade A)
| A National Clinical Guideline
Context/Category BTS/SIGN - Recommendations GINA - Recommendations
Factors contributing to
difficult asthma
Allergy In patients with difficult asthma and recurrent hospital
admission, allergen testing to moulds should be performed
(Grade C)
Treating modifiable Exacerbation risk can be reduced by optimising asthma
risk factors to reduce medications, and by identifying and treating modifiable risk
exacerbations factors
| A National Clinical Guideline

Risk Factor: Any patient with >= risk factor for exacerbations
(including poor symptom control)

Treatment Strategy:
• Ensure patient is prescribed regular ICS-containing
controller (Evidence A)
• Ensure patient has a written action plan appropriate for
their health literacy (Evidence A)
• Review patient more frequently than low risk patients
(Evidence A)
• Check inhaler technique and adherence frequently
(Evidence A)
• Identify any modifiable risk factors (Evidence D)
Risk Factor: >=1 severe exacerbation in last year

Treatment Strategy:
• consider alternative controller regimes to reduce
exacerbation risk e.g. ICS/formoterol maintenance and
(aged 16 years and older)

reliever regimen (Evidence A)


• consider stepping up treatment if no modifiable risk
factors (Evidence A)
• identify any avoidable triggers for exacerbations
(Evidence C)
| Management of an Acute Asthma Attack in Adults
119
Context/Category BTS/SIGN - Recommendations GINA - Recommendations 120
Risk Factor: Exposure to tobacco smoke

Treatment Strategy:
• encourage smoking cessation by patient family; provide
advice and resources (Evidence A)
• consider higher dose of ICS if asthma poorly-controlled
(Evidence B)
Risk Factor: Low FEV1 especially if <60% predicted

Treatment Strategy:
(aged 16 years and older)

• Consider trial of 3 months treatment with high dose ICS


and/or 2 weeks OCS (Evidence B)
• Exclude other lung disease e.g. COPD (Evidence D)
• Refer for expert advice if no improvement (Evidence D)
Risk Factor: Obesity

Treatment Strategy:
• Strategies for weight reduction (Evidence B)
• Distinguish asthma symptoms from symptoms due to
| Management of an Acute Asthma Attack in Adults

deconditioning mechanical restriction and/or sleep


apnoea (Evidence D)
Risk Factor: Major psychological problems

Treatment Strategy:
• arrange mental health assessment (Evidence D)
• help patient to distinguish between symptoms of anxiety
and asthma; provide advice about management of
panic attacks (Evidence D)
Risk Factor: Major socioeconomic problems

Treatment Strategy:
• Identify most cost-effective ICS based regimen (Evidence
D)
| A National Clinical Guideline
Context/Category BTS/SIGN - Recommendations GINA - Recommendations
Risk Factor: Confirmed food allergy

Treatment Strategy:
• Appropriate food avoidance; injectable epinephrine
(Evidence A)
Risk Factor: Allergen exposure if sensitized

Treatment Strategy:
• Consider trial of simple avoidance strategies; consider
| A National Clinical Guideline

cost (Evidence C)
• Consider step up of controller treatment (Evidence D)
• The efficacy of allergen immunotherapy in asthma is
limited (Evidence A)
Risk Factor: Sputum eosinophilia (limited centres)

Treatment Strategy:
• Increase ICS dose independent of level of symptom
control (Evidence A)
Specialist Settings/
Populations
(aged 16 years and older)
| Management of an Acute Asthma Attack in Adults
121
Context/Category BTS/SIGN - Recommendations GINA - Recommendations 122
Acute asthma Give drug therapy for acute asthma as for non-pregnant ICS prevent exacerbations of asthma during pregnancy
management in patients including systemic steroids and magnesium (Evidence A) and cessation of ICS during pregnancy is a
pregnancy sulphate (Grade C) significant risk factor for exacerbations (Evidence A)

Deliver high flow oxygen immediately to maintain On balance given the evidence in pregnancy for adverse
saturation 94–98% (Grade D) outcomes from exacerbations (Evidence A) and for safety
of usual doses of ICS and LABA (Evidence A) a low priority
Acute severe asthma in pregnancy is an emergency and should be placed on stepping down treatment (however
should be treated vigorously in hospital (Grade D) guided) until after delivery (Evidence D)
(aged 16 years and older)

Continuous fetal monitoring is recommended for acute


severe asthma. (good practice point)

For women with poorly controlled asthma during


pregnancy there should be close liaison between the
respiratory physician and obstetrician, with early referral
to critical care physicians for women with acute severe
asthma. (good practice point)
| Management of an Acute Asthma Attack in Adults
| A National Clinical Guideline
Context/Category BTS/SIGN - Recommendations GINA - Recommendations
Acute asthma Oxygen
management in primary In severe exacerbations, controlled low flow oxygen
care therapy using pulse oximetry to maintain saturation at 93-
95% is associated with better physiological outcomes than
with high flow 100% oxygen therapy (Evidence B). However,
oxygen therapy should not be withheld if pulse oximetry is
not available (Evidence D).

Inhaled short acting β2 agonists


| A National Clinical Guideline

For mild to moderate exacerbations, repeated


administration of inhaled SABA (up to 4-10 puffs every 20
minutes for the first hour) is usually the most effective and
efficient way to achieve rapid reversal of airflow limitation
(Evidence A).

Delivery of SABA via pMDI and spacer leads to a similar


improvement in lung function as delivery via nebulizer
(Evidence A); however acute severe asthma were not
included in these studies.

Controlled oxygen therapy (if available)


Controlled or titrated oxygen therapy gives better clinical
outcomes than high-flow 100% oxygen therapy (Evidence
B).

Systemic corticosteroids
OCS should be given promptly especially if the patient is
deteriorating or had already increased their reliever and
(aged 16 years and older)

controller medications before presenting (Evidence B)

The recommended dose for adults is 1mg prednisolone/


kg/day or equivalent up to a maximum of 50 mg/day. OCS
should usually be continued for 5-7 days (Evidence B).
| Management of an Acute Asthma Attack in Adults
123
Context/Category BTS/SIGN - Recommendations GINA - Recommendations 124
Treatment in acute care Inhaled short acting β2 agonists
settings such as the Inhaled SABA therapy should be administered frequently
emergency department for patients presenting with acute asthma. The most cost
effective and efficient delivery is by pMDI with a spacer
(Evidence A).

There is no evidence to support the routine use of


intravenous β2 agonists in patients with severe asthma
exacerbations (Evidence A).
(aged 16 years and older)

Systemic corticosteroids
Systemic corticosteroids speed resolution of exacerbations
and prevent relapse and should be utilized in all but the
mildest exacerbations in adults (Evidence A).

Dosage: daily doses of OCS equivalent to 50mg


prednisolone as a single morning dose or 200 mg
hydrocortisone in divided doses are adequate for most
patients (Evidence B).
| Management of an Acute Asthma Attack in Adults

Duration: 5 and 7 day courses in adults have been found


to be as effective as 10 and 14 day courses respectively
(Evidence B). Evidence from studies in which all patients
were taking maintenance ICS after discharge suggests that
there is no benefit in tapering the dose of OCS, either in the
short term or over several weeks (Evidence B).

Evidence from studies in which all patients were taking


maintenance ICS after discharge suggests that there is no
benefit in tapering the dose of OCS either in the short term
or over several weeks (Evidence B).

Inhaled corticosteroids
Within the emergency department: high dose ICS given
within the first hour after presentation reduces the need
for hospitalization in patients not receiving systemic
corticosteroids (Evidence A). When given in addition to
systemic corticosteroids evidence is conflicting (Evidence
B).
| A National Clinical Guideline
Context/Category BTS/SIGN - Recommendations GINA - Recommendations
On discharge home: the majority of patients should
be prescribed regular ongoing ICS treatment since the
occurrence of a severe exacerbation is a risk factor for
future exacerbations (Evidence B).

ICS containing medications significantly reduce the risk


of asthma related death or hospitalization (Evidence A).
There was some evidence however that post discharge
ICS were as effective as systemic corticosteroids for
| A National Clinical Guideline

milder exacerbations but the confidence limits were wide


(Evidence B).

Other treatments:
Magnesium
Intravenous magnesium sulfate is not recommended
for routine use in asthma exacerbations; however when
administered as a 2g infusion over 20 minutes it reduces
hospital admissions in some patients including adults with
FEV1 <25-30% predicted at presentation (Evidence A).

While the overall efficacy of this practice is unclear pooled


data from three trails suggest possible improved pulmonary
function in those with severe asthma exacerbations (FEV1
<50% predicted) (Evidence B)

Helium oxygen therapy


A systematic review of studies comparing helium oxygen
with air oxygen suggests there is no role for this intervention
(aged 16 years and older)

in routine care (Evidence B).

Non-invasive ventilation
If NIV is tried the patient should be monitored closely
(Evidence D). It should not be attempted in agitated
patients and patients should not be sedated in order to
receive NIV (Evidence D).
| Management of an Acute Asthma Attack in Adults
125
Context/Category BTS/SIGN - Recommendations GINA - Recommendations 126
Follow up after After emergency department presentation comprehensive
emergency department intervention programs that include optimal controller
presentation or management inhaler technique and elements of self-
hospitalization management education (self-monitoring, written action
plan and regular review) are cost effective and have
shown significant improvement in asthma outcomes
(Evidence B).
Self-Management
Supporting self- A hospital admission represents a window of opportunity
(aged 16 years and older)

management to review self-management skills. No patient should leave


hospital without a written personalised asthma action plan
(good practice point)

An acute consultation offers the opportunity to determine


what action the patient has already taken to deal with the
asthma attack. Their self-management strategy may be
reinforced or refined and the need for consolidation at a
routine follow up considered (good practice point)
| Management of an Acute Asthma Attack in Adults

A consultation for an upper respiratory tract infection or


other known trigger is an opportunity to rehearse with the
patient their self-management in the event of their asthma
deteriorating (good practice point)

Education should include personalised discussion of issues


such as trigger avoidance and achieving a smoke-free
environment to support people and their families living with
asthma (good practice point)

Brief simple education linked to patient goals is most likely


to be acceptable to patients (good practice point)
Self-management in Prior to discharge inpatients should receive written
secondary care personalised asthma action plans given by health care
professionals with expertise in providing asthma education
(Grade A)
| A National Clinical Guideline
Context/Category BTS/SIGN - Recommendations GINA - Recommendations
Self-management in Culturally appropriate supported self-management
ethnic minority groups education should be provided for people with asthma
in ethnic minority groups. Addressing language barriers is
insufficient (Grade B)

Consideration should be given to:


• translation of materials into community languages with
ethnically appropriate pictures
• asthma educators fluent in community languages
| A National Clinical Guideline

• identifying culturally appropriate support agencies within


the local community
• inclusion of culturally specific beliefs and practices
• reference to culturally appropriate role models
• involvement of a local community health worker to
support clinical teams (good practice point)

Self-management of Inhaled corticosteroids


worsening asthma and In placebo controlled trials temporarily doubling the dose
exacerbations of ICS was not effective (Evidence A)

In adult patients with an acute deterioration high dose ICS


for 7-14 days (500-1600mcg BDP-HFA equivalent) had an
equivalent effect to a short course of OCS (Evidence A)

Combination low dose ICS (budesonide or beclometasone)


with rapid onset LABA (formoterol)
The combination of rapid onset LABA (formoterol) and
(aged 16 years and older)

low dose ICS (budesonide or beclomethasone) in a single


inhaler as both the controller and reliever medication is
effective in improving asthma control and in at risk patients
reduces exacerbations requiring OCS and hospitalizations
(Evidence A). The combination ICS/formoterol inhaler may
be taken up to a maximum total formoterol dose of 72
mcg in a day (Evidence A).
| Management of an Acute Asthma Attack in Adults
127
Context/Category BTS/SIGN - Recommendations GINA - Recommendations 128
Self-management of Medication Short term change Evidence Level
worsening asthma in (1-2 weeks) for
adults with a written worsening asthma
asthma action plan Increase usual
reliever:
Short acting β2 Increase frequency A
agonist of SABA use
(SABA) For pMDI add A
spacer

Low dose ICS/ Increase frequency A


(aged 16 years and older)

formoterol of reliever use


(maximum
formoterol total 72
mcg/day)
Increase usual
controller:
Maintenance Continue A
and reliever ICS/ maintenance ICS/
formoterol formoterol and
increase reliever
| Management of an Acute Asthma Attack in Adults

ICS/formoterol
as needed (max
formoterol total
72mcg/day)
Maintenance At least double ICS; B
ICS with SABA as consider increasing
reliever ICS to high dose
(maximum 2000
mcg/day BDP
equivalent)
Maintenance ICS/ Quadruple B
formoterol with maintenance
SABA as reliever ICS/formoterol
(maximum
formoterol
72 mcg/day
| A National Clinical Guideline
Context/Category BTS/SIGN - Recommendations GINA - Recommendations

Maintenance ICS/ Step up to higher D


salmeterol with dose formulation of
SABA ICS/salmeterol or
as reliever consider adding a
separate ICS inhaler
(to maximum total
2000 mcg/day BDP
equivalent)

Add oral
| A National Clinical Guideline

corticosteroids
(OCS) and contact
doctor:
OCS (prednisone or Add OCS for severe A
prednisolone) exacerbations
(E.g. PEF or FEV1
<60% personal
best or predicted)
or patient not
responding to
treatment over 48
hours

Adults: D
prednisolone 1mg/
kg/day (maximum
50 mg) usually for
5-7 days.

Tapering is not B
(aged 16 years and older)

needed if OCS are


prescribed for <2
week
| Management of an Acute Asthma Attack in Adults
129
Context/Category BTS/SIGN - Recommendations GINA - Recommendations 130
Other combination ICS/LABA controllers
For adults taking combination ICS/LABA as a fixed dose
maintenance controller medication, the ICS dose may be
increased by adding a separate ICS inhaler (Evidence D).
More research is needed to standardize this strategy.

Leukotriene receptor antagonists


For patients using a leukotriene receptor antagonist (LTRA)
as their controller there are no specific studies about how
to manage worsening asthma. Clinician judgement should
(aged 16 years and older)

be used (Evidence D).

Oral corticosteroids
For most patients the written asthma action plan should
provide instructions for when and how to commence OCS.
Typically a short course of OCS is used (e.g. 40-50 mg/day
usually for 5-7 days, (Evidence B) for patients who:

- fail to respond to an increase in reliever and controller


medication for 2-3 days
| Management of an Acute Asthma Attack in Adults

- deteriorate rapidly or who have a PEF or FEV1 <60% of


their personal best or predicted value

- have a history of sudden severe exacerbations

Patients should contact their doctor if they start taking OCS


(Evidence D).
| A National Clinical Guideline
Context/Category BTS/SIGN - Recommendations GINA - Recommendations
Follow up after a self- After a self-managed exacerbation patients should see
managed exacerbation their primary care health care provider for a semi-urgent
review (e.g. within 1-2 weeks) for assessment of symptom
control and additional risk factors for exacerbations, and
to identify the potential cause of the exacerbation. The
written asthma action plan should be reviewed to see if it
met the patient’s needs. Maintenance controller treatment
can generally be resumed at previous levels 2-4 weeks
after the exacerbation (Evidence D) unless the history
| A National Clinical Guideline

suggests that the exacerbation occurred on a background


of long-term poorly controlled asthma. In this situation,
provided inhaler technique and adherence have been
checked a step up in treatment is indicated.
(aged 16 years and older)
| Management of an Acute Asthma Attack in Adults
131
Appendix 13 Tool 13: Evaluation Sheet – search and selection of evidence 132

“Acute adult asthma management” Guideline 1: BTS/SIGN Guideline 2: GINA

Yes Unsure No Comment Yes Unsure No Comment

Overall was the search for evidence comprehensive? Y Y

The author had a clearly focused question (population, intervention, Y Y


outcome)

Appropriate databases were searched for source guidelines Y Y

Internet sites were searched for source guidelines Y U Not reported


(aged 16 years and older)

Years covered in search Y Y

Languages covered in search U Not reported Y English

Keywords used Y Y

Combinations of keywords Y Y

Detailed search strategies are provided with the guidelines Y N

Snowball methods were used U Not reported U Not reported


| Management of an Acute Asthma Attack in Adults

A hand search of the reference lists was completed N p.19 SIGN 50 U Not reported

Local experts and/or societies were asked for guideline recommendations U Not specific U Not specific
to asking for to asking for
recommendations recommendations
| A National Clinical Guideline
Guideline 1: BTS/SIGN Guideline 2: GINA
Yes Unsure No Comment Yes Unsure No Comment
Overall was bias in the selection of articles avoided? U U
Inclusion and exclusion criteria reported U Not explicit U Not explicit
The number of persons who selected and analysed the data is Y Number of Y p.vi 2 members
documented people who evaluate and ans.
analysed was Q’s on scientific
2; selection not impact
reported
The procedure to solve disagreement is described Y SIGN 50 Y Consensus/Voting
| A National Clinical Guideline

@ meetings
The number of references analysed is documented N N
The number of excluded references is documented N N
The reasons for excluding references are given N N
The criteria for inclusion and exclusion are clinically & methodologically U I & E criteria not U I & E criteria not
valid explicit explicit
The reasons for exclusion conform to the selection and exclusion criteria U Not reported U Not reported
The process for selection of evidence is adequately described N N
Comment Followed SIGN 50; actual Comments The actual process from
process from searching evidence to searching the evidence to extracting data
extracting data in evidence tables not in the evidence tables was not reported;
reported; no PRISMA diagram no PRISMA diagram
(aged 16 years and older)
| Management of an Acute Asthma Attack in Adults
133
Appendix 14: Tool 14: Evaluation sheet – scientific validity of guidelines 134

(Consistency between evidence, its interpretation and recommendations)

Health Question – “Acute asthma management in adults” Guidelines 1: BTS/SIGN Guideline 2: GINA

Yes Unsure No Comment Yes Unsure No Comment

Overall the evidence was valid Y Y

Given the search strategy, the risk that relevant evidence has been missed is low Y U Complete
search
strategy not
(aged 16 years and older)

explicit

The criteria for selecting the evidence is explicit Y Y

Settings and protocols of selected studies fit with the health question Y Yes and if Y
different
reported

Outcomes were clinically sound (e.g. duration of disease-free survival might be Y Y


considered too weak as evidence compared to overall survival)

The criteria used for assessing the quality and validity of the selected studies are Y Y
| Management of an Acute Asthma Attack in Adults

adequately reported (type of studies, randomization methods, patient’s retention


in groups etc.)

The risk that biased evidence has been reported is low Y Evidence clearly Y Evidence
presented clearly
presented

When a meta-analysis was performed, statistical analyses were appropriate. N/A N/A
Sensitivity analysis and test of heterogeneity was performed
| A National Clinical Guideline
Health question – “Acute asthma management in adults” Guideline 1: SIGN/BTA Guideline 2: GINA

Yes Unsure No Comment Yes Unsure No Comment

Coherence between the evidence and recommendations Y Y

The evidence was direct. Patients and interventions included in the studies were Y Y
comparable to those targeted by the recommendations

Conclusions were supported by data and/or the analysis; results were consistent Y Y
from study to study. When inconsistencies existed in data, considered judgement
was applied and reported.

The conclusions are clinically relevant. (Statistical significance is not always equal Y Y
| A National Clinical Guideline

to clinical significance)

The conclusion derived from data point to effectiveness/ineffectiveness of the Y Y


intervention and the recommendations are written accordingly

There is some justification to recommend/not recommend the intervention even Y Y


though the evidence is weak

The hierarchy of strength of evidence is adequately described Y Y

Overall, the scientific quality of the recommendations do not present risks of bias Y Y

The strength of evidence attributed to the recommendations is adequately Y Y


described and justified

Risks and benefits have been weighed Y Y

Comments Comments
(aged 16 years and older)
| Management of an Acute Asthma Attack in Adults
135
Appendix 15: Tool 15: Evaluation sheet – Acceptability/Applicability 136

Health Question – Acute asthma management in adults Guidelines 1: SIGN/BTA Guideline 2: GINA

Yes Unsure No Comment Yes Unsure No Comment

Overall the recommendations are acceptable Y Y

The strength of evidence and the magnitude of effect adequately Y Y


support the grade of the recommendations

There is sufficient benefit of the intervention compared with other Y Y


available management
(aged 16 years and older)

The recommendations are compatible with the culture and values in the Y Y
setting where it is to be used

Overall the recommendations are applicable Y Y

The intervention is applicable to the patients in the context of use Y Y

The intervention/equipment is available in the context of use Y Y

The necessary expertise is available in the context of use Y Y

There are no constraints, legislation, policies, or resources in the health Y There might be Y
care setting of use that would impede the implementation of the some implications
| Management of an Acute Asthma Attack in Adults

recommendations for smaller


hospitals in terms
of resources
for example
recommendations
for referral and
transfer to ICU
which may need
consideration /
management by
specific hospital
groups.

Comments Comments
| A National Clinical Guideline
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(aged 16 years and older) 137

Appendix 16: Glossary of Abbreviations


ABG Arterial blood gas
AGREE 11 Appraisal of Guidelines for Research and Evaluation
AMU Acute Medical Unit
AMAU Acute Medical Assessment Unit
BUN Blood Urea Nitrogen
BTS British Thoracic Society
BVM Bag Valve Mask
CAG Clinical Advisory Group
CCM Chronic Care Model
CEO Chief Executive Officer
CEU Clinical Effectiveness Unit
CF Cystic Fibrosis
CMO Chief Medical Officer
CNS Clinical Nurse Specialist in Respiratory care
COAX Cost of Asthma Exacerbations
COPD Chronic Obstructive Pulmonary Disease
CO2 Carbon Dioxide
CPI Consumer Price Index
CPG Clinical Practice Guidance
CPD Continuous Professional Development
CSO Central Statistics Office
CXR Chest X-ray
DALY Disability Adjusted Life year
DARE Database of Abstracts of Reviews and Effects
DCU Dublin City University
DMP Disease Management Programme
DOB Date of Birth
DOH Department of Health
DPS Drug Payment Scheme
EBP Evidence Based Practice
ECG Electrocardiogram
ED Emergency Department
EFR Emergency First Response
EU/EN 13826 European Union Scale (for peak flow meters)
FBC Full Blood Count
FEV1 Forced Expired Volume in one second
GDG Guideline Development Group
GINA Global Initative for Asthma
GMS General Medical Services
GP General Practitioner
GPOOH GP Out of Hours
H+ Hydrogen acid
HIPE Hospital In-patient Enquiry
HSE Health Service Executive
IARS Irish Association of Respiratory Scientists
ICER Incremental Cost Effectiveness Ratio
ICGP Irish College of General Practitioners
ICU Intensive Care Unit
IM Intramuscular
ITS Irish Thoracic Society
IV Intravenous
kg kilogram
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138 (aged 16 years and older)

MAU Medical Assessment Unit


MOCA Model of Care for Asthma
mg miligram
min minute
NCEC National Clinical Effectiveness Committee
NCG National Clinical Guideline
NCPA National Clinincal Programme for Asthma
NHS National Health Service
NIV Non-invasive ventilation
NMBI Nursing and Midwifery Board of Ireland
O2 Oxygen
OOH GP Out of Hours Service (see GPOOH above)
OPD Outpatients Department
PEF Peak Expiratory Flow
pH Numeric scale used to specify the acidity or alkalinity
PHECC Pre-Hospital Emergency Care Council
PICO Population, Intervention, Comparison, Outcome
PN Practice Nurse
pMDI pressurised Metered Dose Inhaler
PPP Purchasing Power Parity
PRISMA PRospectIve Study on asthMA control
QALY Quality Adjusted Life Year
RCPI Royal College of Physicians of Ireland
RCT Randomised Control Trial
RTI Respiratory Tract Infection
SABA Short Acting Beta Agonists
SCr Serum creatinine
SIGN Scottish Intercollegiate Guideline Network
SOB Shortness of Breath
SPO2 Oxygen Saturation
UCD University College Dublin
UK United Kingdom
USA United States of America
WG Working Group
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(aged 16 years and older) 139

Appendix 17: Budget impact assessmenta


Appendix 17.1. Economic impact report

Key message
This review of the literature on the economic evaluation of the acute asthma management in adults and
the budget impact analysis supports the clinical guideline recommendations.

The report was completed by Prof. Patrick Manning, Consultant Respiratory Physician and
Clinical Lead for National Clinical Programme for Asthma (NCPA), Noreen Curtin (Programme
Manager NCPA 2012-2013) and Michelle O’Neill, Senior Health Economist, Health Technology
Assessment Directorate, Health Information and Quality Authority in collaboration with Prof
Stephen Lane, Chair (Clinical Advisory Committee-NCAP), Dr. Ina Kelly, Specialist in Public
Health Medicine (NCAP), Dr Kathleen Mac Lellan, Director of Clinical Effectiveness, CMO Office,
Department of Health and Mr. Gethin White, Clinical Librarian, Health Service Executive (HSE)
library services.

Background
The overarching aim of the National Clinical Programme for Asthma (NCPA) is to reduce the
morbidity and mortality associated with asthma in Ireland and to improve clinical outcomes and
the quality of life for all patients with asthma. A key component is improved management of
people with asthma in primary care and thereby avoiding emergency asthma attendance at
GP out of hours services (GPOOH – estimated 21,800 adult visits annually) and at hospital ED and
in-patient admission services. There is a good scientific rational for this approach and this work
has been shown to be effective at international levels with significantly improved outcomes
focusing on improving asthma control in the community and thereby reducing asthma morbidity
and mortality overall. This includes reduced adult acute asthma attendances at Emergency
Departments (currently estimated at about 12,000 adult visits annually), in-patient admissions
in hospital (currently about 1,460 adult admissions annually) and accounting for 5,825 acute
bed days used, of which 70 patients had an ICU admission utilising 222 ICU bed days. (Hospital
In-patient Enquiry - HIPE 2011) Patients with acute asthma exacerbations are at an increased
risk of death (currently about 1 per week (most asthma deaths occur in adults)) and 90% of
deaths from asthma are preventable. Acute attendances and admissions may have their roots
in prior inadequate care in the community and in a lack of patient involvement in controlling
symptoms through guided self-management. Poorly controlled asthma is costly; the efforts in
the community at primary and specialist care levels should be firmly focused on achieving and
maintaining good control in as many patients as possible. As much as a third of the overall cost
of managing asthma may be related to emergency attendances, hospitalisation and death,
with hospitalisation accounting for between 20 and 25% of the overall cost (5). The Asthma
Society of Ireland has estimated the cost of asthma care in the Republic Of Ireland is of the
order of €6.5 million and due largely to uncontrolled asthma. Much of this cost relates to adult
admissions and the estimated cost in 2005 as identified in an international study to determine the
Cost Of Asthma exacerbations (20) was €3,809 per patient per admission but this is equivalent to
€4,733 in 2013. (CSO/CPI for health).

Annual Estimated Cost for 1460 x €4733.2 adult admissions: €6.9m

International research has identified that the majority of hospital admissions for asthma are
emergency admissions, of which 70% may have been preventable with appropriate early
intervention (21, 22) Many people with asthma have poor control of their condition and in a

a See Appendix 5.4 list of References for Economic Evaluation Literature Review where ‘Reference’ is indentified in text
| Management of an Acute Asthma Attack in Adults | A National Clinical Guideline
140 (aged 16 years and older)

large scale survey in the UK reported that around 35% of adults with asthma had had an asthma
attack in the previous 12 months (The Health Survey for England found that 30-40% of people
with asthma had had an asthma attack in the previous 12 months)(23). Poorly controlled
asthma is more expensive than well controlled asthma for the NHS. The annual cost of an NHS
patient who has an exacerbation of asthma requiring hospital treatment is likely to be 3.5 times
that of a patient who does not. It is expected that it is similar in the Republic of Ireland. Thus,
there is significant scope for reducing overall community costs for asthma by improving disease
control through implementing a programme of guideline based chronic disease management
at primary care level linked when necessary to specialist care for all patients with asthma and
appropriate management of exacerbations as outlined in these acute guidelines for adult
asthma. This is what is envisaged in the National Model of Care for Asthma.

NCPA Model of Care for Asthma


The NCPA has developed a Model of Care for Asthma (MOCA) which details how physicians,
nurses, and other health care professionals will work with engaged patients to make the clinical
decisions most appropriate to their circumstances by implementing international evidence-
based guideline care in chronic disease as well as acute management; and to collaborate with
specialist colleagues in providing a safe, seamless patient experience within the health system
in Ireland. MOCA has been approved by the HSE Leadership Team and it is envisaged that it will
be published by the end of 2015.

The implementation of the MOCA will ensure that patients with asthma will benefit from being
part of a well-managed integrated system of care, coordinated at primary care level and
financed to support seamlessness and patient-centeredness.

The team at primary care level will deliver ongoing high quality health care for patients with
asthma with 24/7 access to care. This team will be led by an experienced general practitioner
(GP) with knowledge and training in asthma care, with a trained practice nurse that will educate,
support and enable patients to effectively manage their asthma. The community pharmacist
will assist the GP in asthma management by communicating concerns about patient’s control
and providing patient education on inhaler technique and peak flow monitoring. They will
also advise patients on asthma drug therapies and potential drug interactions (medicine use
review). GPs will refer patients to the specialist service in secondary care who will assist the GP to
manage ‘difficult to control’ asthma in the community and be responsible for monitoring acute
asthma care in ED and acute medical unit (AMU)/ acute medical assessment unit (AMAU).

If necessary, people with asthma will be admitted for acute management and stabilisation
in accordance with best practice guidelines. International evidence demonstrates that
implementing a national asthma management programme over a number of years can reduce
asthma hospitalisations by 50%, cost per patient by 30%, and deaths from asthma by 90% (24).

Implementation Plan for Model of Care for Asthma


Work is currently underway by the NCPA to develop an implementation plan for MOCA. The
MOCA identifies implementation to occur in phases. The initial phase will focus on patients
(both adults and children) with acute asthma who attend GPOOH services and also those who
attend ED and/or are admitted for acute asthma (estimated at about 70,000 in total). Some
recommendations such as the use of guidelines and asthma education training are already
underway, whereas, other recommendations such as patients attending a structured review
as outlined in the Asthma Check document (25) at primary or secondary specialist care have
yet to be implemented and thus will likely have resource implications. The annual structured
review will require approximately 30 minutes of practice nurse time and 10 minutes of GP time. If
spirometry is required additional time should be booked. This structured asthma review will focus
on optimising treatment, ensuring institution of inhaled corticosteroid therapy early in asthma
management where appropriate, encouraging medication adherence and address underlying
| A National Clinical Guideline | Management of an Acute Asthma Attack in Adults
(aged 16 years and older) 141

problems with asthma care and management and will include some or all of the following with
the patient and/or caregiver:
• Inhaler technique
• Adherence to and understanding of asthma medications
• Self-management education including personal asthma plans and self-monitoring
• Management of co-morbidities and triggers including allergic rhinitis
• Smoking cessation and/or avoidance or exposure to second hand smoke

The Acute Asthma Guidelines for adults


Since the goal of asthma management is to achieve and maintain control of asthma symptoms,
which should be achievable in the majority of people with asthma, for most people, the best
outcome of on-going effective management of asthma means that they will not experience
acute attacks and exacerbations. However for a significant minority, urgent need for healthcare
is an unfortunate but often on-going aspect of their asthma. An acute exacerbation requiring
hospital attention at Emergency Departments (ED) or in-patient care represents a serious failure
of asthma control. In that situation, patients will need to have access to local, easily accessible
and competent services in an emergency, which may be their GP practice, GP out-of-hours/
urgent care services (GPOOH), ED and in-hospital care. About 15% of patients relapse following
an acute exacerbation, especially if seen in an ED, due to unresolved airway inflammation.

This guideline provides clear guidance for the assessment and treatment of acute asthma in
general practice, by paramedic services, the Emergency Department and in the acute hospital
for adults. The guideline articulates clear criteria for when patients with acute asthma should be
admitted and discharged. The guidelines also mention that if clinical staff fail to assess severity of
an acute exacerbation by an objective measurement and under-use corticosteroids it can lead
to poor outcomes including avoidable deaths and thus education is required around guideline
managed care.

This guideline for adults (along with the NCPA’s acute asthma guideline for paediatrics (26))
is a significant management tool, based on current international best practice and will assist
in appropriate management and follow up of acute exacerbations of asthma. Patients with
an acute exacerbation of asthma are at increased risk of death and readmission for asthma if
not managed appropriately. Patients who attend GPOOH, ED and those who are admitted to
hospital for acute asthma should be followed up by attending their GP within 2 working days
of discharge for ongoing asthma management. International best practice recommends that
all patients admitted to hospital should be followed up on discharge from hospital in a medical
specialist clinic for 1 year (in conjunction with their GP) until stable.

The implications for service development for acute guideline implementation


• All HSE staff involved with patients experiencing an asthma exacerbation should have
appropriate training in arranging rapid assessment for asthma, in all healthcare settings in
which patients may attend in an emergency.
• Ambulance staff may be the first health care professionals that people will encounter in an
emergency. They need to have the right skills and training to provide support before they
can reach more specialist treatment. They also need to be able to distinguish between
people who need hospitalisation and those who could safely be redirected to community
services.
• GP Out–of-hours (GPOOH) centres are increasingly the first port of call for people experiencing
an asthma exacerbation. Therefore medical/nursing staff in these settings need to be as
well-trained as in all other settings and in particular need to have close communication with
primary care to ensure prompt and appropriate follow-up after the episode. It is particularly
important that out-of-hours services are aware of people at greatest risk of having an attack,
are knowledgeable and competent in dealing with asthma attacks.
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142 (aged 16 years and older)

• Hospital staff, including ED and in-patient hospital personnel involved in triage, assessment
and management of acute asthma should have the appropriate knowledge and training
in acute asthma assessment and ongoing care for this condition.
• There is over-use of nebulisers in acute situations. Delivery of short acting bronchodilators
by nebuliser instead of by standard inhaler with a spacer can encourage a reliance on
hospital care, and lead to repeat hospital attendances by patients, when delivery using an
inhaler and spacer may be adequate. This guideline recommends that Hospital Emergency
Departments, GPOOH and urgent care centres do not use nebulisers routinely for treatment
of acute attacks, except where appropriate.
• Patients who are admitted to hospital should be managed in a ward where staff, including
nurses, have adequate training and experience in monitoring acutely ill asthma patients
and are proficient at administering appropriate medications for this.
• Every acute hospital admissions unit should have a senior clinical individual who is responsible
for ensuring that asthma care across all departments conforms to the Irish Acute Asthma
Attack in Adults Guideline, and to ensure that records and audit processes and outcomes
are identified and stored.
• Implementation of bundles of care for acute asthma care to encourage adherence to best
practice guidelines is recommended locally.

Economic literature review results


A systematic review of the economic evaluation literature of acute asthma was conducted, the
detailed search terms are provided in Table 9 (Search Methodology) and a flow diagram of the
retrieved studies in Figure 2, all the studies are listed in the References for Economic Evaluation
Literature Review section in Appendix 5.4. Of the 54 studies identified, 34 were excluded from
analysis. One was not available, (27) and 33 studies did not report any relevant economic data
(28-60). These latter 33 studies reported on drug therapy in a chronic disease management
setting leading to better ongoing asthma control outcomes as per Irish current management
asthma guidelines (61) based on international evidence-based clinical practice. The outcome
of this enhanced control of asthma leads to less asthma exacerbations, out-of-hours GP
(GPOOH) attendances, Emergency Department (ED) attendances, hospital/ICU admissions
and possibly deaths from acute asthma. This economic analysis is outside the scope of these
current acute management guidelines and will be addressed in a future NCEC submission of
the chronic management asthma guidelines. The remaining 20 studies (references 62-79) cover
a broad range of topics covering five main areas and are closely linked with implementation
of the guidelines on acute asthma. These topics include: a) costs of asthma exacerbations
and hospital admissions in adult patients with asthma both internationally and in the Republic
of Ireland; b) asthma education for healthcare professionals as part of regional and national
implementation programmes; c) outcomes of implementation of asthma clinics; d) rationale for
prescribing steroids especially inhaled steroids at the time of an exacerbation and; e) the cost
of using a multidose inhaler (MDI) reliever with a spacer device for acute asthma compared to
the usual wet nebulisation in acute care settings such as hospitals and EDs. The costs presented
have been inflated and converted into 2013 values for Ireland using the relevant national
Consumer Price Index (CPI) and Purchasing Power Parity (PPP) unless otherwise stated.

A. Costs of asthma exacerbations and hospital admissions (references 62-67)


Cost in the Republic of Ireland were identified in the international observational
prospective study to determine the Cost Of Asthma exacerbations (COAX) study (20): This
prospective study (20), which was reported in 2006 involved a total of 15 countries including
the Republic of Ireland. It assessed the local cost of asthma exacerbations managed in
either primary or secondary care. Healthcare resources used were costed using actual
values appropriate to each country in local currency and in Euros. Results are presented for
exacerbations managed in primary care in Brazil, Bulgaria, Croatia, Czech Republic, Hungary,
Poland, Russia, Slovakia, Slovenia, Spain and Ukraine, and in secondary care in Croatia,
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(aged 16 years and older) 143

Denmark, Ireland, Latvia, Norway, Poland, Russia, Slovakia, Slovenia and Spain. Multiple
regression analysis of the 2,052 exacerbations included in the economic analysis showed that
the cost of exacerbations was significantly affected by country (P<0.0001). Mean costs were
significantly higher in secondary care (€1349) than primary care €445 (P=0.0003). Age was a
significant variable (P=0.0002), though the effect showed an interaction with care type i.e. older
adults needing hospital care had increased costs compared to younger adults (P<0.0001). As
severity of exacerbation increased, so did secondary care costs, though primary care costs
remained essentially constant. In conclusion, the study showed that asthma exacerbations
are costly to manage, suggesting that therapies able to increase asthma control and reduce
the frequency or severity of exacerbations may bring economic benefits, as well as improved
quality of life.

In addition, international studies (references 62-66) have identified that asthma exacerbations
leading to emergency management and in-patient hospitalisations can be costly through both
direct and indirect costs. Direct costs include emergency care, hospital admissions, associated
tests and management and the cost varies depending on the asthma exacerbation severity.
In a study of 401 asthma patients in northern California USA (published in 2003, data from 1998),
the annual average cost of adult hospital admissions was €564 accounting for 15% of costs, In
Canada (published in 2013, data in abstract form from 2011), the average hospitalisation costs
per acute asthma episode ranged from €306 to €617 and the average costs for ED visit per
acute asthma episode ranged from €146 to €184, excluding medication cost. The analysis of
the cost of asthma in Spain (which included emergency care, hospital admissions, and tests)
showed that the average annual cost of asthma in adults in Spain (published in 2009, data from
2007) comes to €2,275 per patient, considering both direct and indirect costs. The average
annual cost per patient to the Spanish National Health Service is €2,021. In both Korea (2012)
and the USA (2012), the burden of asthma was higher for patients with poorly controlled asthma
and in USA, asthma patients (12-64 years) with exacerbations vs those without exacerbations
had significantly higher asthma-related costs [$1740 vs $847, (€1450 vs €700) P<0.0001]. Sixty-eight
international studies reviewed between 1966-2008 found that hospitalisation and medications to
be the most important cost driver of direct costs. Recommendations from this review included
strategies for including education of patients and physicians in asthma assessment and care,
and regular follow-up being required to reduce this economic burden of asthma.

B. Asthma education for healthcare professionals (References 24,67,68)


In the early 1990s the Ministry of Social Affairs and Health in Finland (pop. 5.2 million) set up a
national asthma programme in conjunction with the Finnish Lung Health Association (24). The
main objectives for the programme were improved and early diagnosis of asthma in the
population, patient education and self-management, reduction in tobacco exposure and
research with a view to stopping the escalating costs of managing the condition. A key goal
was an asthma educational programme for key healthcare professionals in the community (GP,
practice nurses and pharmacists) and in secondary care. The key to implementation was an
effective network of asthma responsible professionals. The main premise was that asthma is an
inflammatory disease requiring anti-inflammatory therapy (with inhaled corticosteroids) from the
onset. The outcome from the 10 year programme (1994-2004) identified that while the incidence
of asthma increased over that time, the burden of asthma to the community decreased
considerably through implementing the programme. The number of hospital days fell by 54%
from 110,000 in 1993 to 51,000 in 2003, 69% in relation to the number of people with asthma
(n = 135,363 and 207,757, respectively), with the trend remaining downwards. In 1993, 7,212
patients of working age (9% of 80,133 people with asthma) received a disability pension from
the Social Insurance Institution compared with 1,741 in 2003 (1.5% of 116,067 people with
asthma). The absolute decrease was 76%, and 83% in relation to the number of people with
asthma. The increase in the cost of asthma (compensation for disability, drugs, hospital care,
and outpatient doctor visits) ended: in 1993 the costs were €218 million which had fallen to
€213.5 million in 2003. Costs per patient per year decreased 36% (from €1,611 to €1,031). The
| Management of an Acute Asthma Attack in Adults | A National Clinical Guideline
144 (aged 16 years and older)

programme was run by the Finnish Lung Health Association (Filha)b, and employed one
pulmonologist. Overall, the direct extra cost of the programme was €0.65 million including
€125,000 from the Finnish Ministry of Social Affairs and Health who gave their political
commitment to the programme. The intervention was managed by integrating the tasks into the
everyday practice of healthcare staff. The conclusion of the project was that it is possible to
reduce the morbidity of asthma and its impact on individuals as well as on society through a co-
ordinated programme including health professional Education on asthma exacerbations. A
similar programme is outlined in detail in the Irish National Clinical Programme for Asthma‘s
Model of Care.

[Asthma statistics in Finland for the period 1981–1996 showing a relative increase in the number
of patients entitled to special reimbursement for their drug costs and decreases in the death
rate and days in hospital for these patients (index, 1981 = 100)].

Asthma education for emergency department staff can also be effective in improving asthma
care. In a study from Kuwait (67) a new policy was implemented in a single acute hospital
emergency department (which is planned in Ireland outlined in the National Model of Care
for Asthma). This policy was aimed at reducing medical admissions to overcome the problems
of a shortage of inpatient beds, overcrowding, rising costs and exhausted resources. A key
component was the implementation of disease management guidelines for a number of
medical conditions including acute asthma and was prospectively studied over a period of 3
years from introduction of the policy and compared with the 3-year period before the policy
was instituted. The outcome was a significant reduction in admission rates after introduction of
the new policy with a relative reduction of 49.2% for bronchial asthma.

Internationally hospitalisation and medications were found to be the most important cost
driver of direct costs. In an international review of 68 studies between 1966-2008, (68)
recommendations were identified which included strategies for including education of patients
and physicians in asthma assessment and care, and regular patient follow-up by educated
healthcare professionals being required to reduce the economic burden of asthma.

b Filha is a Finnish non-governmental organisation (expert NGO, www.filha.fi)


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(aged 16 years and older) 145

C. Asthma clinics (References 69-75)


These studies showed that compared with those who received only primary care, patients
who received secondary care showed evidence of more appropriate controller treatment. In
addition, the disease management programme (DMP) in secondary care is associated with
a gain in QALYs compared to usual care (2.7+/-.2 versus 3.4+/-.8), at lower costs (€3,302+/-314
versus €2,973+/-304), thus leading to dominance (69). Organizing health care according to the
principles of disease management for adults with asthma has a high probability of being cost-
effective and is associated with a gain in QALYs at lower costs (70).

Mogasale et al. investigated the cost-effectiveness of providing asthma education, promotion


of self-monitoring of symptoms, regular review of treatment by a medical practitioner and a
written asthma action plan to current practice in Australia (71). When a potential $85 million in
cost-savings from decreased emergency department visits, GP visits and hospitalisations is taken
into account, the ICER was $17,000 per DALY averted. The study concluded that an asthma
clinic as an intervention for improving self-management may be cost-effective in Australia if
multiple benefits can be achieved.

Victoria Rogers et al. reported on a quality improvement programme evaluatingthe impact


of implementing elements of the Chronic Care Model (CCM) (in three clinical sites at Maine
Medical Center) (MMC) in the USA (72). This programme was undertaken in order to decrease
visits and associated costs connected with asthma hospitalisations and ED visits with yearly
comparisons beginning July 2001 (July 1, 2001 through June 30, 2002). They identified patients
with asthma from three clinic sites (Family Practice, Internal Medicine, and Paediatrics). These
sites implemented an intervention consisting of a redesigned team approach, an emphasis
on patient self-management skills, and the use of registries to track populations of patients. It
is planned that a similar intervention will be implemented in Ireland at primary and secondary
care levels as outlined in the National Model of Care for Asthma. There was a very substantial
reduction in asthma-related ED visits and hospitalisations in all three sites varying from 51% in
Internal Medical Clinic, 40.7% for the BBCH Paediatric Clinic and 36.5% for the Family Practice
Center. The reduction among the clinic patients was far greater than the 5.5% reduction in
asthma ED visits and hospitalisations observed for all patients using the MMC during the same
time period. The difference in utilization among clinic patients resulted in savings of about
€50,000 [US$60,000 x 0.832 = PPP (IRE, 2013)] over the year under review. There was also a
moderate reduction in non-asthma related ED visits and hospitalisations for the clinic population.

About 20% or more of adult asthma patients may develop a repeat exacerbation requiring
ED attendances and/or early re-admission to hospital within 1 month of discharge (73, 74).
Much of this relates to suboptimal discharge management following the initial admission and
thus is creating a potentially avoidable burden for patients and medical services. Involvement
and follow up in an asthma nurse / respiratory specialist clinic has been shown to reduce re-
hospitalisation rates to 0% with asthma nurse specialist input (75). If admitted to hospital for
acute asthma it is recommended that patients be followed up in a specialist medical outpatient
department (OPD) for 1 year until stable (adult asthma patients following an acute exacerbation
may not followed up in the medical OPD on discharge). Occasionally patients may be followed
in specialist medical OPD indefinitely if they have more severe or difficult to control asthma.

D. MDI reliever with spacer device for acute asthma compared to wet nebulisations
(References 76-77)
Cates et al. evaluated the use of the reliever therapy for acute asthma as MDU or wet
nebulisation and searched the Cochrane Airways Group Trial Register and reference lists of
articles (76). This search included a total of 1,897 children and 729 adults in 39 randomised
control trials. Thirty-three trials were conducted in the emergency room and equivalent
community settings, and six trials were on in-patients with acute asthma (207 children and 28
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146 (aged 16 years and older)

adults). Nebuliser delivery produced outcomes that were similar to metered-dose inhalers
delivered by spacer in adults. Method of delivery of inhaled β2 agonists reliever medication did
not appear to affect hospital admission rates. The MDI/spacer can also be cheaper and thus
may be a more economical alternative to wet nebuliser delivery. Dhuperet al. (77) reported
that demonstration of equivalent efficacy of β2 agonist delivery using a metered dose inhaler
(MDI) with a spacer device compared to using a wet nebuliser in asthma patients. However,
the median cost of treatment per patient was $10.11 (SD $10.03-$10.28) vs. $18.26 (SD $9.88-
$22.45) in the spacer and nebuliser groups, respectively (p < 0.001). They concluded that
there is no evidence of superiority of nebuliser to MDI/spacer β2 agonist delivery for emergency
management of acute asthma in this inner-city adult population. Thus the MDI/spacer may be
a more economical alternative to wet nebuliser delivery in patients other than those with severe
exacerbations. This evidence supports Recommendation 11 of the Management of an Acute
Asthma Attack in Adults Guideline.
| A National Clinical Guideline | Management of an Acute Asthma Attack in Adults
(aged 16 years and older) 147

Appendix 17.2. Budget-Cost implications for implementation of acute adult guidelines


The cost implications for implementation of these guidelines in adults were reviewed as follows:

Budget impact of the proposed guidelines


The cost impact analysis focuses on two (2) costing areas:

1. Staff training
The main costs for guideline implementation is the costs associated with structured training
for clinical staff in hospital and GPOOH settings on acute asthma guideline managed care.
It is critical that medical staff involved with acute asthma patients have the knowledge and
training to manage these patients appropriately.

2. Possible additional cost implications arising from implementing the guidelines


Additional costs that have been reviewed but are essentially either cost neutral or are
associated with implementation of an overall Asthma Model of Care Chronic Disease
Management Programme for primary care linked to specialist care, include the following:
• Recommendation that a spacer device is used with a pressurized multidose inhaler
(pMDI) inhaler in mild-moderate asthma exacerbations rather than wet nebulisation for
salbutamol bronchodilation where possible.
• Recommendations on medications e.g. inhaled steroids and oral steroids in acute
asthma exacerbations.
• Recommendation of follow up with GP within 2 working days of discharge from ED.
• Recommendations on follow up in the medical specialist/nurse led OPD clinic for 1 year
for patients admitted to hospital with acute asthma following discharge.
• Recommendation that all patients have a peak flow meter reading on admission to
GPOOH, ED and Hospital.

Costs of staff training on guidelines implementation:


This is the main cost associated with implementation of the acute asthma guideline for adults.

Nurses: Hospital and practice nurses in primary care (PNs) and Out of Hours (OOH) Nurses
The National Asthma Programme and the Asthma Society of Ireland (ASI) have developed an
online asthma education programme which is aimed at the healthcare professional. The course
contains two components, 6 x 30 minute e-learning modules based on GINA guidelines (these
should be completed within 6 months of commencement) and an additional practical workshop
(½ day session – 3 hr). This workshop is delivered by Respiratory Clinical Nurse Specialists. The HSE
have employed a service level agreement (SLA) with ASI to cover the cost of this e-learning
package so there is no direct cost to the person undertaking the training. The SLA cost €29,084
per year from 2011 – 2014 with a total cost of €116,336. This SLA will continue in 2015. However,
the SLA with ASI includes time for work on the educational programme along with other aspects
(patient information, development of chronic asthma guidelines, national MOC etc.) thus it is
not possible to apportion costs to acute asthma guidelines time.

The e-learning training is mandatory for Practice Nurses (PNs) and is optional for nurses/staff
working in secondary care. However, all nurses should undertake the ½ day workshop on asthma
practical skills (asthma management plans, medications, guidelines implementation and follow
up, peak flow readings and inhaler technique).

I. Costs of attendance at training

To cost the staff time for education, an average salary at staff nurse grade (HSE, 2013) was
assumed for those attending. This includes staff time attending training and clinical nurse
specialist (CNS) time delivering training.
| Management of an Acute Asthma Attack in Adults | A National Clinical Guideline
148 (aged 16 years and older)

This is envisaged as a once off training cost so that after initial training the onus is on the individual
to maintain competence.

II. Cost to deliver training

Total Nurse Costs:

The cost for training the 2,085 nurses [Hospital and practice nurses in primary care (PNs) and Out
of Hours Nurses (OOH)] targeted as outlined in the National Model of Care for Asthma to attend
half day workshop (assume average of 10 staff on workshop). This would require CNS to provide
209 half day workshops at an approximate cost of €26,334 i.e. CNS salary x (209 x 3 hours). The
cost for the HSE nurses (excluding the PNs) above to attend a 3 hour workshop is approximately
€124,380 and for Out of Hours nurses training €14,670. However, for primary care practice nurses
(PNs) training places are included for these nurses to attend when slots are available i.e. as part
of the 10 nurses slots (their time to attend is provided by the GP practice). Although staff costs
are quantified above, these are an opportunity cost in that staff are released from other duties
to attend/deliver trainingc.

NCHD training
This is undertaken by the consultant specialists as part of medical education (undergraduate
and post graduate). There is no implementation cost for this.

Consultants training
Updated training on their own time assisted by local Asthma Medical/Respiratory Consultant
Lead. (This is completed in non-specialist consultant own time and is not included in costs).
Consultants are funded for CME updates as part of their contract of employment. Each acute
hospital site admitting adult patients with acute asthma have an assigned designated local
lead (approx. 35). It is envisaged that the local Asthma Medical/Respiratory Consultant lead
may have to provide 3, three hourly teaching sessions per year. The hourly cost for local asthma
consultant lead is estimated at €88/hourd. Each session (including preparation time) estimated
costing €264.00.

Opportunity Local Asthma Lead costs €264 x 3 x 35 sites = €27,720 / year

GP training
An on-line education programme has been developed by the ICGP in conjunction with the
National Clinical Programme for Asthma.
Access is free of charge for members of the ICGP.
(This is completed in one’s own time and not included in costs).

GP practice nurse training


While there are no costs for PNs to partake in the training there may be some opportunity cost
to the GP practice in that staff may need to be released from other duties from the practice so
they can attend the half day practical training
This is a cost to the GP practice and not the HSE.

c Salary formula as per Budget Impact Analysis of Health Technologies in Ireland was used for both grades and formula as per
Regulatory Impact Analysis used with adjustment for nursing hours.
d In line with consolidated salary scales in accordance with clause 2.31 of the Haddington Road agreement http://www.hse.ie/
eng/staff/Benefits_Services/pay/nov13.pdf
| A National Clinical Guideline | Management of an Acute Asthma Attack in Adults
(aged 16 years and older) 149

Pharmacist training
In addition a number of pharmacists and other health professionals have registered for this
programme.

This is completed in the pharmacist’s own time and not included in the costs of the programme.

Pre-hospital emergency care practitioner training


Pre-hospital emergency care practitioners have ongoing educational programmes which
include acute asthma management and are included in these guidelines.
There is no extra cost envisaged with this training.

Table 6 Cost of attendance for training HSE associated staff


Profession Training Salary Scales Total cost
Number
Nurses (HSE) 1,382 €30/hr x 3hr = €90 per training €124,380
(hospital based in session
ED, AMU-AMAU Departments) (1,382 HSE hospital nurses x
€90 = €124,380)

Practice nurses 540 No salary costs to HSE (GP) No HSE salary cost
(primary care)

GP out of hours (GPOOH) nurses 163 As per HSE nursing above €14,670
(HSE supported) €90 x 163 = €14,670
Local Medical/Respiratory 35 sites €264 x3 x35 sites = €27,720 €27,720
Consultant Hospital Asthma Lead
may have to provide up to 3
teaching sessions per year.

Clinical Nurse Specialist (CNS) 2,085 Training session is 3hrs = €126 €26,334
Respiratory – costs as trainers (HSE, PNs, OOH (@ €42/hour)
nurses) There are 209 sessions x 3
Nurses for hours required to complete
training training of staff
€126 x 209 = €26,334
Cost of attendance at training for HSE staff = €193,104
| Management of an Acute Asthma Attack in Adults | A National Clinical Guideline
150 (aged 16 years and older)

Table 7 Cost of attendance at training for other staff


Profession Numbers for Salary Scales Total cost
training
NCHD training in acute asthma None
(as part of PG
training)
GP training As part of ICGP CME/
CPD
GP practice nurse No cost to HSE but
there is a cost to GP
practice for time
Pharmacist None
Pre-hospital emergency care None
practitioners training (as part of PG
training)

Possible additional cost implications

Possible additional cost implications arising from implementing the guidelines recommendations
include:

A. Recommendation that a spacer device is used with a pressurized multidose inhaler (pMDI)
inhaler in mild-moderate asthma exacerbations rather than wet nebulisation for salbutamol
bronchodilation where possible.

The acute guidelines recommend that as standard practice that the reliever salbutamol, be
given for relief of bronchospasm. However, in many cases current practice is that this is given by
a nebuliser and face mask usually in an acute setting such as GPOOH or hospital ED. However,
international guidelines have recommended for some time that in cases of mild to moderate
exacerbations salbutamol should be given as a pMDI using a spacer device (either Volumatic®
or disposal once off paper spacer). The rationale for this approach is that patients will learn to
treat acute asthma symptoms using their own salbutamol inhaler at home rather than attend
needlessly to ED or GPOOH for nebulisation therapy. In addition, as part of the proposed Asthma
Watch chronic disease management (CDM) structured review patient education will focus on
managing exacerbations with a pMDI and spacer with advice as to when to attend ED and
GPOOH if this is ineffective. The pMDI and the nebuliser devices are equally effective for the
delivery of bronchodilators in the acute care setting. However, in such cases where pMDI and
spacers are used, a wet nebuliser will need to be available in GPOOH or ED in case a mild-
moderate exacerbation progresses and/or the reliever response is poor with the pMDI and
spacer and in cases where patients present with more severe exacerbation cases. (76, 77)

Advantages of pMDI with a spacer vs wet nebuliser therapy


• This guideline recommends that Emergency Departments in Hospital and GPOOH and
urgent care centres do not use nebulisers routinely for treatment of acute attacks, except
where appropriate.
• Metered-dose inhalers (pMDI) with a spacer can perform at least as well as wet nebulisation
in delivering β2 agonists in acute asthma and the total dose of salbuterol given to patients is
lower with MDI/spacer delivery.
• The MDI/spacer can also be cheaper and thus may be a more economical alternative to
wet nebuliser delivery (51). The patient outcomes are similar and include the length of stay
| A National Clinical Guideline | Management of an Acute Asthma Attack in Adults
(aged 16 years and older) 151

in the emergency department for adults (although in children this was reduced). Peak flow
and forced expiratory volume were also similar for the two delivery methods.
• The main advantage of using the pMDI with spacer approach is that it will reduce patient
over-use of nebulisers in acute situations for less severe exacerbations. Often, patients focus
on nebuliser therapy instead of standard inhaler with spacer and as these are generally
not available at home this can encourage a reliance on hospital care, and lead to repeat
hospital attendances by some patients for wet nebuliser although pMDI and spacer would
be adequate.

Possible costs
The Volumatic® spacer or paper spacer requires less storage space and at similar cost. Many
patients already use a spacer device but are unlikely to bring to an acute care setting. The cost
of the Volumatic® spacer under the community drug scheme is €3.34 (Feb 2014). The Volumatic®
pacer (single patient use) can be supplied to the patient on discharge from hospital (about 80%
of patients). The annual potential costs of this approach is as follows: GPOOH attendances =
21,800 (€72,812) and ED attendances = 12,000 (€40,080). The annual possible savings, less use of
nebulisers $8* x 27,040 (80%), converted from $ to € PPP, IRE, 2013 = 0.832.

Possible total costs: €112,892


Possible savings: $216,320 or €179,978
Possible savings: on non-attendances to ED and GPOOH

*Dhuperet al. reported equivalent efficacy of β2 agonist delivery using a metered dose inhaler
(MDI) with a spacer device compared to using a wet nebuliser in asthma patients. However,
the median cost of treatment per patient was $10.11 (SD $10.03-$10.28) vs. $18.26 (SD $9.88-
$22.45) in the spacer and nebuliser groups, respectively (p < 0.001). They concluded that there
is no evidence of superiority of nebuliser to MDI/spacer β2 agonist delivery for emergency
management of acute asthma in this inner-city adult population. Thus the MDI/spacer may be
a more economical alternative to wet nebuliser delivery in patients other than those with severe
exacerbations.

B. Recommendations on medications e.g. inhaled steroids and oral steroids in acute asthma
exacerbations.

• Stat dose of oral steroids in an acute exacerbation of asthma

In ED or in-patient, patients may be given a stat dose of oral steroids (stat doses = few cents)
and on discharge and leaving hospital (ED or in-patient), may be given a prescription for a full
course of oral steroids (paid by patient or through medical card). [MIMS Ireland publication on
GMS drug therapy, shows the cost of Deltacortril EC® i.e. oral steroids at €9.90/100 tablets, the
stat doses is usually 6 tablets at €0.60 and 5 days x 6 tablets or €3.00 per course.

Possible total costs:


Stat doses - steroids €0.60 x 33,800 patients (ED and GPOOH) = €20,280
(The full course of 5 days of treatment at €3/course would be €101,400)

C. Recommendation of steroid inhaler therapy with short acting reliever inhaler

Inhaled steroid therapy


Fitzgerald and Gibson in the review article from 2006 on asthma exacerbation examined current
knowledge of prevention in asthma exacerbations (78). They noted that the optimal strategies
for the prevention of asthma exacerbations include the early introduction of anti-inflammatory
treatment, most commonly this was low dose inhaled corticosteroids and recommended that
this policy should be coupled with a structured education programme which has a written
| Management of an Acute Asthma Attack in Adults | A National Clinical Guideline
152 (aged 16 years and older)

action plan as an integral component.  In addition Blais et al. (79) reported on a case-control
study nested within a cohort of 13,563 newly treated subjects with asthma selected from the
databases of Saskatchewan Health (1977–1993). This study was undertaken to investigate the
effectiveness of a first treatment with inhaled corticosteroids in preventing admissions to hospital
for asthma. Study subjects were aged between five and 44 years at cohort entry. First time users
of inhaled corticosteroids were compared with first time users of theophylline for a maximum
of 12 months of treatment. The conclusion from the study was that the first regular treatment
with inhaled corticosteroids initiated in the year following the recognition of asthma reduced
the risk of admission to hospital for asthma by up to 80% compared with regular treatment with
theophylline. This is probably due, at least in part, to reducing the likelihood of a worsening in
the severity of asthma.

On leaving hospital (ED or in-patient), inhaled steroid therapy should be prescribed as a


preventer for all patients with an acute asthma exacerbation as well a short acting reliever
inhaler for break through asthma symptoms. It is not envisaged that these inhaled medications
would be supplied to the patient on leaving the ED so this may incur additional costs for patients
without full medical cards on filling prescription but no costs to hospital and GPOOH as the
patient is given a prescription but not the medications. Patients with medical cards will have
access to this therapy without significant additional costs. However, even though prescribed,
people with asthma do not always take their recommended treatment. This may be due to poor
communication between healthcare professionals and those with asthma, lack of opportunity
to discuss fear of side effects, omission of shared decision making, and the patient not feeling
in control. Even if patients take their medication, many do not do so correctly i.e. poor inhaler
technique, which will lead to suboptimal outcomes through poor asthma control which is
costly leading to further exacerbations, GPOOH and ED attendances and hospital admissions.
Therefore following discharge from ED patients should attend their GP for follow up of asthma
and if admitted receive specialist follow up for 1 year at least in the medical out-patient service.

Possible costs: Undetermined (may include drug costs under GMS or DPS schemes)

D. Recommendation of follow up with GP within 2 working days of discharge from ED.

As part of the guidelines the patient will attend their GP for follow up of their asthma within 2
working days. There are potential costs with GP visits and it is recommended in the NCPA Model
of Care that patients will enter the annual assessment or Asthma Check structured review which
likely will attract increased costs at primary care level which are as yet undetermined. Central
to the implementation process will be the standardisation of an asthma review. This will optimise
treatment, ensure institution of inhaled corticosteroid therapy early in asthma management
where appropriate, encourage medication adherence and address underlying problems with
asthma care and management and include:
• Inhaler technique
• Adherence to and understanding of medications
• Self-management education including personal asthma plans management of co-
morbidities and triggers including allergic rhinitis
• Smoking cessation and/or avoidance or exposure to second hand smoke.

Possible costs: Undetermined (but likely to attract increased costs for implementation of Asthma
Check annual review of patients with asthma at primary care level).

E. Recommendations on follow up in the medical specialist/nurse led OPD clinic for 1 year for
patients admitted to hospital with acute asthma following discharge.

About 20% or more of adult asthma patients may develop a repeat exacerbation requiring
ED attendances and/or early re-admission to hospital within 1 month of discharge (73,74).
| A National Clinical Guideline | Management of an Acute Asthma Attack in Adults
(aged 16 years and older) 153

Involvement and follow up in an asthma nurse / respiratory specialist clinic has been shown
to reduce re-hospitalisation rates to 0% with asthma nurse specialist input (75). If admitted to
hospital for acute asthma it is recommend that patients be followed up in a specialist medical
OPD for 1 year until stable. Occasionally patients may be followed in specialist medical OPD
indefinitely if they have more severe or difficult to control asthma.

On average there will likely be 4 clinic visits per year (2 nurse led asthma clinic and 2 regular
medical outpatient clinics, start and end of year).

Consultant/Medical OPD x 2 / year =


1,460 patients @ €130/clinic x 2 clinics = €379,600

Nurse specialist x 2 clinics / year (30 minutes per clinic, @ €42/hr.) and
1,460 patients @ €21/clinic (30 minutes) x 2 clinics = €61,320

Costs of service: €440,920

Potential savings:
The national asthma programme envisages that over 3 years of implementation that we expect
a 30% reduction or more in asthma admission. The asthma nurse led clinic linked to the specialist
asthma service would, based on international evidence (75) reduce the admission by 20%
(avoidance of re-admission of patients attending this service commenced within the hospital
prior to discharge and follow up within 1 month of discharge).

Potential savings: Asthma nurse-led clinic 20% reduction in admissions over 1-3 years
= 292 patients x €4,733.2* (admission cost/pt.) = €1.38m

*Coax study (20)

F. Recommendation that all patients have a peak flow meter reading on admission to GPOOH,
ED and Hospital for ongoing assessment and management of acute asthma.

Since this usually forms part of standard medical equipment in hospital, this has not been
included.

Cost: No extra costs envisaged with this


| Management of an Acute Asthma Attack in Adults | A National Clinical Guideline
154 (aged 16 years and older)

Table 8 Estimated costs and possible savings with Implementation of Acute Asthma Attack in Adults
Guideline
Annual Estimated Cost for 1,460 acute asthma adult admissions x [€4733.2 per €6.9m
patient = cost in COAX study (20)]

Costs
Initial Set-up Costs
The HSE cost for Asthma Society of Ireland SLA cost €29,084 per year from July €116,336
2011 – June 2015 (Total)
Cost of attendance at training HSE staff €193,104
Annual ongoing costs
Possible costs spacer and pMDI €112,892
Stat doses – steroids €0.60 x 33,800 patients (ED and GPOOH) €20,280
Steroid inhaler therapy with short acting reliever inhaler Costs: Undetermined
Follow visits with GP after ED discharge Costs: Undetermined
Costs of specialist / nurse led asthma OPD visits for patients discharged after €440,920
acute asthma admissions
Peak flow meters at GPOOH and ED No extra costs
envisaged with this

Possible estimated annual savings


Possible savings: reduced nebuliser use in ED €179,978
Better asthma management by specialist/asthma nurse led / specialist clinic €1,380,000
following discharge leading to non-attendances at ED and GPOOH and
reduced admissions by 20%
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(aged 16 years and older) 155

Appendix 17.3. Economic search methodology

A systematic literature search was performed in October 2013 and in May 2014. The search
strategy used the following PICOS.

Population: Adult Patients >16 years with acute exacerbation of asthma

Intervention: Economic effectiveness of interventions designed to manage acute exacerbations


of asthma in adult patients >16 years

Comparison: Primary vs secondary care, otherwise no specific comparator

Outcome: Most cost effective interventions for managing acute exacerbations of asthma in
adult patients > 16 years.

Inclusion and exclusion criteria


The inclusion criteria were as follows:
• Adult patients over the age of >16
• All studies considered however preference was given to the higher levels of evidence
o Systematic Reviews
o Meta-Analysis
o Clinical Trials
o Evaluation Studies
o Expert Opinion
o Editorials

Studies were excluded if they related to


• Children under the age of <16 years
• Patients suffering with milder forms of asthma
• Outside of the last five years

Children under the age of 16 were not excluded in the search terms for this work as a number of
studies that mainly concentrated on adult asthma also contained some coverage of childhood
asthma therefore to have specifically excluded any references to childhood asthma as a search
term may also have excluded some potentially useful references to acute adult asthma.

Note: The search example included was from the PubMed database. The same search strategy
was also employed on the other noted databases.

Databases Searched
The following databases were utilised in the literature search
• PubMed
• Embase
• Cochrane
• Web of Science
• NHS Evidence
• Google Scholar
• Up To Date
• Clinical Key
• One Search
• Database of Abstracts of Reviews and Effects (DARE)
• NHS Economic Evaluation Database
• Health Technology Assessment Database
| Management of an Acute Asthma Attack in Adults | A National Clinical Guideline
156 (aged 16 years and older)

Table 9 Search methodology


Search Search Criteria Hits
1 ((acute asthma OR severe asthma OR persistent asthma OR asthma exacerbation)) 19047
AND "Asthma"[Mesh]
2 (((((((((((((("Peak Expiratory Flow Rate"[Mesh] OR ("Inhalation Spacers"[Mesh]) OR 105277
"Nebulizers and Vaporizers"[Mesh] AND (("Oxygen"[Mesh]) OR ("Bronchodilator
Agents"[Mesh] OR "Bronchodilator Agents"[Pharmacological Action])) OR
("Glucocorticoids"[Mesh] OR "Glucocorticoids"[Pharmacological Action])) AND
"last 5 years"[PDat])) OR ((((("Ipratropium"[Mesh] OR "fenoterol, ipratropium drug
combination"[Supplementary Concept] OR "albuterol-ipratropium"[Supplementary
Concept]) OR ("Magnesium Sulfate"[Mesh] OR "dipyrithione"[Supplementary
Concept])) OR ("Aminophylline"[Mesh] OR "aminophylline, cycloclenbutrerol,
diphenydramine, phenobarbital drug combination"[Supplementary Concept])) OR
("Leukotriene Antagonists"[Mesh] OR "Leukotriene Antagonists"[Pharmacological
Action])) AND "last 5 years"[PDat])) OR ((("Anti-Bacterial Agents"[Mesh] OR "Anti-
Bacterial Agents"[Pharmacological Action]) OR "Infusions, Intravenous"[Mesh]) AND
"last 5 years"[PDat])) OR ((((("heliox"[Supplementary Concept]) OR "Helium"[Mesh])
OR ("furosemide-albumin complex"[Supplementary Concept] OR "butoxymethylene
furosemide"[Supplementary Concept] OR "furosemide glucuronide"[Supplementary
Concept] OR "Furosemide"[Mesh])) OR "Noninvasive Ventilation"[Mesh]) Filters:
published in the last 5 years
3 ((((((((((((((((((((("Economics"[Mesh] OR "Economics, Medical"[Mesh] OR 1461118
"Economics, Pharmaceutical"[Mesh]) OR "Costs and Cost Analysis"[Mesh]) OR
"Health Care Costs"[Mesh]) OR "Decision Support Techniques"[Mesh]) OR "Models,
Economic"[Mesh]) OR "Markov Chains"[Mesh]) OR "Monte Carlo Method"[Mesh])
OR "Uncertainty"[Mesh]) OR "Quality of Life"[Mesh]) OR "Quality-Adjusted Life
Years"[Mesh])) OR ((economic impact OR economic value OR pharmaco-economics
OR health care cost OR economic factors OR cost analysis OR economic analysis OR
cost OR cost-effectiveness OR cost effectiveness OR costs OR health care cost OR
cost savings OR cost-benefit analysis OR hospital costs OR medical costs OR quality-
of-life))) OR ((econom$ OR cost OR costly OR costing OR costed OR price OR prices
OR pricing OR priced OR discount OR discounts OR discounted OR discounting
OR expenditure OR expenditures OR budget$ OR afford$ OR pharmcoeconomic
OR pharmaco-economics$))) OR (econom$ OR cost OR costly OR costing OR
costed OR price OR prices OR pricing OR primed OR discount OR discounts OR
discounted OR discounting OR expenditure OR expenditures OR budget$ OR afford$
OR pharmacoeconomic OR pharmaco-economics$)) OR ((cost$[All Fields] OR
adj1[All Fields]) OR (util$[All Fields] OR effective$[All Fields] OR efficac$[All Fields] OR
benefit$[All Fields] OR consequence$[All Fields] OR analy$[All Fields] OR minimi$[All
Fields] OR saving$[All Fields] OR breakdown[All Fields] OR lowering[All Fields] OR
estimate$[All Fields] OR variable$[All Fields] OR allocation[All Fields] OR control[All
Fields] OR illness[All Fields] OR sharing[All Fields] OR life[All Fields] OR lives[All Fields] OR
affordable$[All Fields] OR instrument$[All Fields] OR technolog$[All Fields] OR day$[All
Fields] OR fee[All Fields] OR fees[All Fields] OR charge[All Fields] OR charges[All Fields])
AND s[All Fields])) OR ((value OR values OR valuation) AND adj 2 AND (money OR
monetary OR life OR lives OR costs OR cost))) OR ((qol OR qoly OR qolys OR hrqol OR
qaly OR qalys OR qale OR qales))) OR ((sensitivity analys$ OR quality-adjusted life
year$ OR quality adjusted life years$ OR quality-adjusted life expectanc$ OR quality
adjusted life expectanc$))) OR (unit cost OR unit-cost OR unit-costs OR unit costs OR
drug cost OR drug costs OR hospital costs OR health-care costs OR health care cost
OR medical cost OR medical costs)))) Filters: published in the last 5 years
4 #1 AND #2 AND #3 761
5 primary care OR intensive care OR ICU OR hospital admission OR secondary care 49,909
Filters: Systematic Reviews; Review; Randomized Controlled Trial; Practice Guideline;
Meta-Analysis; Guideline; Evaluation Studies; Editorial; Controlled Clinical Trial; Clinical
Trial; Case Reports; published in the last 5 years
6 #4 AND #5 54
| A National Clinical Guideline | Management of an Acute Asthma Attack in Adults
(aged 16 years and older) 157

Figure 2 below is a Flow Diagram of retrieved studies which is a short flow diagram detailing the
numbers of articles retrieved and progress through the economic search.

Records identified through database Additional records identified through


searching other sources
(n =1,873) (n =8 )

Records after duplicates removed


(n =978)

Records screened Records excluded


(n =978) (n =632)
Not relevant 470
Didn’t meet criteria

Full-text articles
Full-text articles
assessed for eligibility
excluded,
(346+8)
(300)
(n =354)

Studies included in
qualitative synthesis
(n =54)

Figure 6 Flow Diagram of Retrieved Studies


| Management of an Acute Asthma Attack in Adults | A National Clinical Guideline
158 (aged 16 years and older)

Appendix 18: References


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2010 applied to 2011 Irish population data by appropriate age groups. Asthma Society of
Ireland
3 Helping Asthma in Real Patients. The Harp Study Preliminary Report, July 2009 Kelly I,
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4 Weiss KB Sullivan SD The Health Economics of Asthma and Rhinitis. 1 Assessing the economic
impact. J Allergy Clin Immunol 2001: 107(1):3-8.
5 Asthma Society of Ireland. The Case for Change: Implementing the national clinical
programme for asthma, 2014.
6 Department of Health UK, An Outcomes of Strategy for Chronic Obstructive Pulmonary
Disease (COPD) and asthma in England, 2011
7 Department of Health UK, An Outcomes Strategy for COPD and asthma: NHS Companion
Document, 2012, p.9. https://www.gov.uk/government/uploads/system/uploads/
attachment_data/file/216531/dh_134001.pdf
8 Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the Management of
Asthma: a National Clinical Guideline. Edinburgh: SIGN; 2014. (SIGN publication no. 141)
9 Central Statistics Office. Vital Statistics Reports 2002 to 2010
10 Royal College of Physicians, Why asthma still kills: The National Review of Asthma Deaths
(NRAD) Confidential Enquiry report May 2014. Healthcare Quality Improvement Partnership
2014 (UK). www.rcplondon.ac.uk/sites/default/files/why-asthma-still-kills-full-report.pdf
11 The ADAPTE Collaboration. 2009. The ADAPTE Process: Resource Toolkit for Guideline
Adaptation. Version 2.0. Available from http://www.g-i-n.net
12 Brouwers M, Kho ME, Browman GP, Cluzeau F, Feder G, Fervers B, Hanna S, Makarski J on
behalf of the AGREE Next Steps Consortium. AGREE II: Advancing guideline development,
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